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A PRACTICAL TREATISE 



ON 



Thi Disuses of m M m M. 



GEORGE THOMAS JACKSON, M.D. 

Instructor in Dermatology in the New York Polyclinic ; Assistant 

Visiting Physician to the New York Skin and Cancer 

Hospital ; Member of the New York 

Dermatological Society ; etc. 



/ '' 




„ JUL 20 1882 ;/) 



l^'EW YOEK : 
E, B, TEE AT, m Broadway. 

JSS7, Price, $2.75, 






COPYRIGHT, 1887. 

By 
E. B. TREAT, N. Y. 



I'RIEFACE. 

The author of this work, five years ago, was in need 
of some complete treatise upon the diseases of the hair; 
and finding none of recent date, excepting such as 
were rather of a popular than a scientific character, he 
began those studies which have resulted in the present 
volume. 

The aim of this book is to present to the medical pro- 
fession a concise statement of what is known of the 
diseases of the hair and scalp; special attention being 
given to their diagnosis and treatment. To this end 
a great number of medical journals have been con- 
sulted, and all available books upon the hair have been 
read. 

The chapter upon the anatomy of the hair is drawn 
chiefly from Waldeyer's ''Atlas der Menschlichen 
und Tierischen Haare,^^ Lahr, 1884; and from Unna's 
article upon the anatomy of the skin in the last num- 
ber of Zierassen's '' Handbuch der speciellen Pathologie 
und Therapie.''^ Leipzig, 1883. Those diseases of 
the scalp which occur as part of a general disease of 
the integument have been described briefly, since all 
text books on dermatology treat fully of them. 

In the Journal Literature there will be found but 
few references to papers which have appeared prior to 



ISCO. In the last twenty- Jpive years our knowledge of 
the disease of the hair has so advanced that many 
of the views held by writers of an earher date are 
no longer of practical value. Where experience has 
shown that the older writers were right, their princi- 
ples and practice have been absorbed into the general 
sum of our knowledge, and are to be found in all sys- 
tematic treatises upon the skin. For these reasons the 
year 1860 has been chosen arbitrarily as a dividing line, 
and the hterature of the following years only has 
been consulted. The Bibhography contains the titles 
of books which deal solely with the hair, and also of 
general treatises upon the skin which have been con- 
sulted. Such references as have not been accessible 
to the author he has indicated by grouping together 
and having them printed in smaller type. 

The author takes great pleasure in acknowledging 
in this place his obhgations and expressing his thanks 
to his friends Dr. George Henry Fox and Dr. Edward 
B. Bronson, and to his brother Eev. S. M. Jackson, for 
valuable suggestions and kindly criticisms during the 
composition of this book. The greater number of the 
illustrations which add so much to the value of the 
work axe from the large collection of photographs be- 
longing to Dr. G-eorge Henry Fox, who placed them 

most generously at the author's disposal 

» 

No. 14 E. 31ST St., New York, 

March 1, 1887. 



CONTENTS. 



PAET I. 



General Considerations. 

CHAP. PAGE 

I. Anatomy of the Hair, . . . . - . 21 
II. Physiology of the Hair, .... 31 

III. Hygiene of the Scalp and Hair. . . . 60 

PAET II. 
Essential Diseases of the Hair. 

IV. Canities, . 63 

V. Changes in the Color of the Hair other 

than turning Gray, . ... .74 

VI. Alopecia, 80 

VII. Alopecia Areata, 105 

YIII. Atrophia Pilorum Propria, . . . 124 

IX. Hypertrophia Pilorum or Hypertrichosis, . 143 

X. Trichiasis and Distichiasis, . . . lc>i^ 

XI. Sycosis 1G4 



PAET m. 

Parasitic Diseases of the Hair. 

CHAP. PAGE 

XII. Trichophytosis Capitis, .... 181 

XIII. Kerion, 209 

XIV. Trichophytosis Barbae, . . . .215 
XV. Favus, 225 

XVI. Pediculosis Capitis, .... 243 

XVII. '' Pubis, 251 

XVIII. Beigel's Disease, and other unusual Para- 

sitic Diseases. .... 258 



PAET IV. 

Diseases of the Hair secondary to Diseases 

OF the Skin. 

XIX. Dandruff, . . . . . . . 265 

XX. Keratosis Pilaris, . . . . . 275 

XXI. Eczema Capitis et Barbae, . . . 279 

XXII. PHca Polonica, 303 

XXIII. Dermatitis Papillaris Capillitii, . . 307 

XXIV. Nsevus Pilosus, 313 

XXV. SyphiHs. Lupus. VitiUgo. . . . 317 



Bibliography and Journal Literature, . . 327 
Index, 353 



CHAPTER I. 

ANATOMY OF THE HAIR. 

Before we can understand the diseases which affect 
the hair, it is necessary for us to have some knowledge 
of its anatomy and physiology. The close connection 
of the sebaceous glands with the hair f oUicles, and the 
fact that disease of the former is very commonly asso- 
ciated with that of the latter, render it essential for us 
to devote a little time to the anatomy and functions of 
these glands. It is true that histologists are not yet 
in perfect accord in regard to some points in the micro- 
scopical anatomy of the hair, and that there are yet 
some unanswered questions in the phenomena of its 
development, growth, fall and regeneration; but, nev- 
ertheless, we know enough to aid us materially in our 
study of its diseases. 

General Description. — The hair is an epidermic 
structure consisting of a root, which is seated in the 
skin and expanded below to form the hulh; and of a 
shaft, which projects beyond the surface of the skin 
and terminates in a point. Its form may be described 
as spindle-shaped, or as a slender cone gradually taper- 
ing to its apex. Its contour is circular, oval or flat- 
tened; and it is either straight, or more or less curled. 
It presents three main varieties: 1. Long, soft hair, 
such as is met with on the head, in the beard, on the 
pubes and in the axillae. 2. Short, stiff hair, such as 
is found in the eyebrows and eyelashes. 3. Lanugo, 
or soft, downy, colorless hair, such as is scattered all over 
the surface of the body, where the other varieties are 
absent. Each hair grows from a small nipple-shaped 



22 DISEASES OF THE HAIR AIH) SCALP. 

connective-tissue projection, the hair papilla, situated 
at the bottom of a deep slender pocket or sac-hke de- 
pression in the skin which is called the hair follicle. 
To each hair folhcle there is attached one or more se- 
baceous glands, which empty by their ducts into its 
upper third. 

The Hair. — The hair is composed of three layers, 
which from within outwards are : 1. The medulla. 
2. The cortex. 3. The cuticle. These are distin- 
guishable even in the deepest part of the hair root, 
and become yet more distinct as we proceed upwards. 
The hairs, excepting those called lanugo, are hollow 
cylinders, the central cavity being filled, in fully formed 
healthy hair, with the medulla, and called the medul- 
lary canal. This canal begins below at the papilla, and 
extends to within a short distance of the point of un- 
cut hairs. In the lanugo hairs it is generally wanting. 
The upper extremity or tip of the hair is pointed, if 
the hair has not been cut; if it has been cut it is flat- 
tened or more or less rounded, depending upon the 
length of time that has intervened between the time 
of cutting and of examination; if a sufficient time has 
elapsed it may even become again pointed. The lower 
extremity of the hair, the root, is expanded to form the 
bulb, which is hollowed out so as to fit accurately hke a 
cap over the nipple shaped papilla upon which it rests. 

The Medulla. — The medulla consists of a column 
of superimposed cells which occupies the cavity of the 
medullary canal. It begins immediately upon the 
upper rounded top of the hair papiUa as a layer of ir- 
regular cubical epithelial cells, each ceU containing one 
or two masses of keratohyahn, which appear as dark 
round drops. Waldeyer (83) tliinks it probable 
that keratohyahn, the '^eleidin" of Eanvier, is 
identical with the " hyalin " of Yon Eecklinghausen, 
which is found in many different kinds of cells. As 



ANATOMY OF THS HA^. ^S 

we trace the medulla higher up in the hair we see that 
the cells, which were dispersed at first irregularly in 
layers, form themselves into a stratified column, like 
a roll of coins, with three or four cells in each horizon- 
tal layer. According to Waldeyer (83) the cells are 
held together by means of delicate projections, and 
when isolated appear like the prickle cells of the skin. 
The lower cells alone have nuclei. As the medulla 
ascends in the hair the cells become more and more 
flattened, the keratohyalin melts into the cell plasma, 
and the nucleus shrivels up and disappears. Then the 
cells themselves shrivel and leave spaces between them, 
which in the middle follicle region are filled with air, so 
that the cells are surrounded by a system of air canals. 
The air does not penetrate the cells. Towards the point 
of the hair the medulla is reduced to a column of single 
cells laid one upon the other. Then the column be- 
comes broken up, greater or smaller spaces forming 
between the cells, till finally it ends. The medulla cells 
sometimes contain pigment. The delicate foetal hairs 
are without a medulla, as are also most of the lanugo 
hairs. As a rule, the greater the diameter of the hair, 
the greater will be the diameter of the medulla. Nev- 
ertheless strong hairs will often be found with propor- 
tionately thin medullae, as is frequently the case in the 
hairs of the human beard. Still more common is it to 
find thin hairs with stout medulLne. Towards the close 
of the life limit of a hair no more medulla cells are pro- 
duced, and in such hairs there is a wide space between 
the bottom of the medulla and the end of the root. 

The Cortex. — The second layer of the hr.ir is the 
cortical substance. This is the substance proper of the 
hair, and consists of long spindle-shaped epithelial cells 
which are flattened out into ^ne bands, and run in the 
long axis of the hair. They are completely cornified 
and contain a shrunken nucleus, which appears as if 



M DISEASES OF THE HAIR AND SCALP. 

pulled out lengthwise; it is wanting entirely towards 
the point of the hair, and is plainly seen only in the 
root. The first cells of the cortex in the neighborhood 
of the papilla are cube-shaped, but under pressure from 
without inwards they become as described above. The 
cortical cells are, hke those of the medulla, provided 
with prickles. In the cortex are found pigment and 
air. The pigment occurs either in the form of 
granules, or diffused. The granular pigment is 
found heaped up in the cells of the cortex, especially 
in those lying peripherally, and sometimes the gran- 
ules are crowded so closely together as to render the 
individual ones indistinguishable. In the upper part 
of the cortex pigment granules may be found lying 
between the cells. The diffused pigment is the essen- 
tial coloring matter of the hair. The air gains entrance 
to the cortex on account of a separation taking place 
between its cells, and is found either in the form of 
rounded, discrete air-globules, or in groups of them, or 
in long streaks. 

The Cuticle. — The third and last layer of the hair 
is the cuticle. It corresponds to the epidermis of the 
skin in location and function. It consists of flattened, 
non-nucleated, fully cornified cells which cover the hair 
Hke scales and are arranged hke shingles on a roof with 
their free ends directed towards the point of the hair. 
In the lower part of the hair root these ceUs are cyHn- 
drical and contain nuclei; but they gradually become 
flattened and lose their nuclei. In the deepest part 
of the shaft of old hairs the cuticle is wanting. 

Hair-Koot. — The root of the hair, with its bulb or 
expanded part, contains all the elements of the hair. 
As the hair shaft descends towards the lower part of 
the hair-follicle it widens more rapidly, and then swells 
out to form the bulb which covers like a cap the papilla, 
excepting at its narrowest part. It results from this 



ANATOMY OF THE HAIR. 



^0 



if^i 







Jjongitudinai Section of Hair Boot, 



26 DISEASES OF THE HAIR AND SCALP. 

that the bulb is hollow below and indented hke the 
bottom of a champagne bottle. The lower part of the 
bulb contains the matrices of the three layers of the 
hair. The matrix of the medulla occupies the part 
corresponding to the top of the papilla, and consists of 
irregular cubic cells. That of the cortical substance 
begins at the side of the body of the papilla, in a layer 
of cyhndrical cells; while that of the cuticle springs 
from the neck of the papilla, and is likewise composed 
of cyhndrical cells. The matrix cells soon begin to 
take on the characteristics of the cells of the different 
layers as we have already learned to know them. The 
sheaths which surround the hair at its root are two 
in number, the hair-foUicle and the root-sheath. The 
hair-foUicle is derived from the cutis, while the root- 
sheath is formed from the epidermis. We may rep- 
resent the arrangement of the hair and its sheaths by 
picturing to ourselves the effect of thrusting, let us say, 
a dull needle into the skin. First there will take place 
a depression of the whole skin, and then the epider- 
mis will be punctured at the lower part of the depres- 
sion and the point will come in contact with the cutis 
below. The cutis will be to the outside and represent 
the hair-follicle, the epidermis will be in the middle 
and represent the root-sheath, while the blunt point 
of the needle will represent the hair-root. 

Hair-Follicle. — The hair follicle is always placed 
at an angle to the skin excepting in the eyelashes, 
where it is perpendicular to the tarsal edge. It is 
found in the upper half of the cutis when it is con- 
nected with lanugo hairs; deeper placed with stronger 
hairs; and in the subcutaneous connective tissue in 
connection with some very coarse hairs; and is from 
one-twelfth to one-fourth of an inch deep. It is a per- 
manent structure, and does not leave its place when a 
bair is plucked from the skin. It begins above at the 



ANATOMY OF THE HAIR. 27 

opening of the sebaceous gland, passes down alongside 
of the hair, and surrounds its lower end forming a 
closed pouch, while some of its fibres enter the hair- 
root from below to form the papilla. It consists of 
three layers; 1. An outer longitudinal fibrous layer of 
ordinary connective tissue. 2. A middle layer of cir- 
cular fibres which are richly studded with long nuclei 
resembling those of smooth muscular fibres; but no 
muscular fibres are present. This layer is the true 
foundation of the follicle, and is the only one that en- 
ters into the formation of the papilla. 3. The vitre- 
ous membrane which is inside of all. It is a thin, 
smooth and homogeneous membrane, which, accord- 
ing to Unna (82 a), is merely a thickening of the inner 
coat of the middle layer of the foUicle, and is only 
found in its lower one third. The older the hair is, the 
more prominent does this membrane become. The 
inside of this membrane, especially in old hairs, is 
thrown into circular or semi-circular projections or 
ridges, which protrude into the prickle-cell layer of the 
outer root sheath in the form of variously sized, duU or 
sharp-pointed teeth. It does not reach to the papiUa. 

Eoot-Sheath. — The root-sheath consists, as usually 
described, of two parts, namely: 1. An external root- 
sheath. 2. An internal root-sheath. Unna (82 a) 
teaches that the external root- sheath should be desig- 
nated as the prickle-cell layer of the hair- follicle, as it 
is genetically different from the internal root- sheath, 
being continuous with the epidermis; while the inter- 
nal root- sheath springs from the hair papilla. The ex- 
ternal root-sheath is continuous above with the epider- 
mis. As it reaches the mouth of the sebaceous gland 
the granular and corneous layers of the epidermis 
cease, and the prickle and cylindrical cell layers proceed 
in full width to near the papilla, where they suddenly 
grow smaller; and finally at the neck of the papilla the^ 



28 DISEASES OF THE HAIR AXD SCALP. 

form a narrow stratum. It is composed of three layers : 
1. An external cylindrical cell layer which is continuous 
with the cyhndrical cell layer of the epidermis, and 
like it is composed of a single row of cells, which pre- 
sent their narrow ends to the vitreous membrane of the 
hair-follicle. 2. A middle prickle cell layer, a continu- 
ation of the same layer of the epidermis. This is the 
thickest of all the layers of the root -sheath. 3. A sin- 
gle layer of flat cells lying next to the outer layer of 
the internal root-sheath. The internal root-sheath 
begins below at the neck of the papilla, and passing 
upwards ends abruptly, as if cut off, at the neck of the 
hair-foUicle, where the sebaceous gland empties into it. 
It consists of three layers, according to most anato- 
mists: 1. An external or Henle's layer. 2. A middle 
or Huxley's layer. 3. An internal or cuticular layer. 
The external or Henle's layer is composed of only a 
single row of flat ceUs. The middle or Huxley's layer 
is usually formed of a single row of short cylmdrical 
ceUs; but when connected with the thick hairs of the 
beard it at times has a second row of cells. The inter- 
nal or cuticular layer is similar in formation to that of 
the hair cuticle, being composed of a single layer of 
flat ceUs which rest one above the other hke scales. In 
the upper regions of the hair-root they are cornified. 
The cuticle of the sheath differs from that of the hair, 
in its cells standing obhque to the long axis of the hair 
and pointing downwards; while those of the hair have 
their long diameter parallel with it and point upwards. 
There thus results an interlocking between them, and 
a fast union, especiaUy in the middle third of the folli- 
cle, so that when a hair is plucked from the skin it 
usually brings with it a part of the internal root -sheath. 
The internal root-sheath can readily be divided into 
two divisions, a lower and an upper. The lower one 
corresponds to the region of the papilla. AIJ its cell^ 



ANATOIMY OF TIIF. HATR. 29 

are nucleated. In the upper region the cells of the 
cuticle are cornified, and those of the Henle layer have 
lost their nuclei. The cells of Huxley's layer preserve 
their nuclei longer, but they become shrunken, and 
finally disappear. Unna (82 a) proposes to do away 
v^ith the terms Henle 's and Huxley's layer, as he re- 
gards them as artificially prepared layers, and to speak 
of the v^hole as the root-sheath. As noted already he 
has dropped the term ^' outer root-sheath," regarding 
it simply as a part of the hair-folHcle. 

The Papilla. — The hair -papilla is situated at the 
bottom of the hair -follicle in connection with its circu- 
lar fibrous layer. It is a wart or nipple- shaped con- 
nective-tissue projection, which penetrates the hair-bulb 
from below. It has a narrow neck, a strongly devel- 
oped, wide middle part or body, and a fine point. 
Upon it the hair rests; and it contains the blood-vessels 
for the chief supply of its nutriment. 

Blood-vessels.— The blood supply of the hair is de- 
rived from arterial branches which surround the hair fol- 
licles in the form of a capillary net-work between their 
middle and external layers; and from smaU arteries 
which penetrate the papilla from below. These arte- 
rial branches are derived from the sub- papillary arte- 
rial anastomosis of the skin. According to Unna (82 a) 
the arteries of the follicles alone are derived from this 
source and enter the follicle in its middle region, the 
arteries of the papillae spring from the deeper circula- 
tion of the cutis. The veins follow the same direction. 

Nerves and Lymphatics.— Nerves have been traced 
to the hair-follicles, but not to the hair-papillae in the 
human subject. Some histologists have follow^ed them 
to the vitreous membrane of the follicle; and Unna 
(82 a) has demonstrated that the prickle-cell layer of 
the external root-sheath is supplied with sensitive 
nerves. He describes the nerve trunks as entering the 



30 DISEASES OF THE HAIR AND SCALP. 

follicles immediately beneath the sebaceous glands, los- 
ing their medulla when they reach the vitreous mem- 
brane through which they pass, and then breaking 
up into branches, which end within the cells with 
double-ended extremities. No lymphatics have yet 
been demonstrated in connection with the hair. 

Arrectores Pilorum. — The muscles of the hair are 
composed of smooth muscular fibres and are named ' 'ar- 
rectores pilorum/' They arise from the lower part of the 
papillary layer, pass downwards beneath the sebaceous 
glands, and are attached with many ends to the middle 
part of many neighboring hair-f oUicles upon the side 
which makes an acute angle with the skui. 

Sebaceous Glands.— The sebaceous glands are of 
the racemose variety, and are found in close connection 
with the hahs of the body, from two to six glands 
emptying into each hair-f oUicle in its upper third. In 
structure they consist of a number of acini which 
empty by a common duct. They are composed of a 
dehcate, structureless capsule, the memhrana propria, 
which continues into the duct, and then merges into 
the vitreous membrane of the hair-f olhcle; and of lin- 
ing cells, which are large, though short, cubical or cy- 
Hndrical epithelial cells, arranged in one or two layers. 
These pass through the duct, and are continuous with 
the cyhndrical cells of the outer root-sheath and of the 
skin. The interior of the gland is filled with the fatty 
secretion. The size of the glands varies in different 
regions, the largest of those connected with the hair, 
being on the nose, measure 2 mm. in diameter in some 
places, and may have as many as twenty acini. Some 
glands are but ^ of an inch in diameter. Their length 
varies in different regions, the longest being on the 
nose. As these glands are offshoots of the hair-folli- 
cles, the external layer of the hair-foUicles passes 
around them and supports their membrana propria. 



CHAPTER II. 

PHYSIOLOGY. 

We have now to consider the phenomena of the de- 
velopment, degeneration, fall and regeneration of the 
hair; its peculiarities of form and constitution; and the 
part it plays in the hfe history of the human being 
whom it clothes. 

Development.— FcETAL Hair. — The germs of the 
future hair appear first upon the face (forehead) and 
eyebrows in the tenth to the twelfth week of foetal life; 
on the lips in the fourteenth week; on the rest of the 
head in the sixteenth week; soon after upon the trunk; 
a few weeks later upon the arms and legs; and at last, 
in the seventh month, upon the backs of the hands and 
feet. The hair itself forms about one month later and 
follows the same order, first coming on the eyebrows, 
and so on. These germs of the future hair are short 
peg-like elevations of the outer embryonal skin. 
Reissner and Gotte considered them swellings of the 
corium; but Waldeyer (83) and Unna (82 a) are in 
accord in teaching that only the stratum Malpighii of 
the epidermis takes part in their formation, the corne- 
ous layer passing smoothly over them. These germs 
are at first separated only by a fine seam of connective 
tissue. An increase and heaping up of round and spin- 
dle-shaped cells then slowly takes place in the cutis 
connective-tissue at the fundus of the germs. At first 
these cells surround each germ like a basket; but soon 
a prominence forms by the cells crowding together at 
one part, and this indents the bottom of the hair germ. 



32 DISEASES OF THE HAIR ATsT) SCALP. 

Thus are formed the primitive hair-f oUicle and the prim- 
itive hair-papilla. According to Waldeyer (83), while 
these changes are taking place in the connective tis- 
sue, the hair-germ sends a slightly knob-shaped pro- 
jection down into the underlying cutis, and the original 
elevation disappears The outer cells of the hair-germ 
now become cylindrical, place themselves crossv^se, 
and appear as a continuation of the basal cells of the 
stratum Malpighii of the skin, while those in the long 
axis of the hair-germ place themselves vertically, grow 
longer and appear, if the papilla has akeady pene- 
trated from below, as a delicate cone-shaped body rest- 
ing on the top of the papilla. This is the primitive 
hair-cone {Haarkegel) of Unna (82 a). 

The cornification of the cells of the primitive hair- 
cone begins at its point, and proceeds rapidly down- 
wards on its external layer till to the point of the hair 
papilla. The lower end of the hair-cone embraces the 
papilla more and more as the upper end grows nearer 
to the outer surface of the skin. Where the hairs 
stand almost perpendicularly to the skin, the grow- 
ing hair-cone drives the corneous layer of the skin be- 
fore it, forming a rounded elevation. This at last 
gives way, and the point of the hair protrudes. Where 
the hair is placed more at an angle to the skin, it some- 
times runs for some distance under the epidermis in a 
spiral manner before piercing it. The middle part of 
the hair-cone grows more rapidly than the outer part, 
and soon breaks through the protecting cell layer of 
the primitive hair -cone as a formed hair, though only 
consisting of cortical substance. The outer layer of 
cells becomes the inner root-sheath and crumbles grad- 
ually away to end at the mouth of the sebaceous gland. 
The remaining cells of the hair-germ, which are still 
to the outside of the external layer of the primitive 
hair-cone, become the outer root- sheath, which is con- 



Mysiology. 33 

tinuous above with the prickle -cell layer of the skin, 
and ends below in a point in the neighborhood of the 
papilla. This is the formation of the primary or foetal 
hairs. The vibrissae, and the hairs of the eyehds, outer 
nose and lips, are placed almost perpendicularly to the 
surface of the skin. In other situations the hairs stand 
at an oblique angle to the surface of the skin, the ob- 
Hquity increasing with the size of the hair, so as to afford 
more space for the lodgement of the hair-follicle. The 
more obliquely the hairs stand, the more plainly do the 
arrectores pili muscles appear, serving to bridge over 
the obtuse angle which the hairs form with the sur- 
face, and to sustain them in position. Where the hairs 
are perpendicular to the skin these muscles do not ex- 
ist. The body of the foetus at the seventh month is 
almost entirely covered with hair, and sometimes this 
condition persists till birth. 

Embryonal Hair Change. — It is no unusual thing 
to see a child born with long, colored hair upon the 
head, and long hght or colorless hair upon the rest of 
the body as weU as on the face. Normally, however, 
in the sixth month, or at the beginning of the seventh, 
the embryonal hair change takes place, commencing 
on the hp. The primitive hair is raised from the pa- 
pilla, and its root end becomes knob-shaped instead of 
cap-shaped. It mounts up in the folhcle till it reaches 
its middle third, where it remains for a time, and con- 
tinues growing, gaining its nourishment from the epi- 
thelial cells of the part. For a time the lower part of 
the follicle remains open, but slowly its epithelial lin- 
ing disappears, it shortens, and the papilla atrophies 
and vanishes. Now a new epithelial process is sent 
out from the lower part of the old hair, passes down- 
wards, enters the lower part of the follicle, making it 
pervious again, and becomes indented from below by 
a new papilla. Then a new growth of hair takes pla 
3 



34 DISEASES OF THE HAIR AND SCALP. 

upon the same principle as in the embryonal hair. 
This process takes place at about the eighth month, 
and is coincident with the fall of the primary hair. 
The fall of the old hair, and the growth of the new, fol- 
lows in the same order as in the first appearance of the 
hair. Even if the child is born with a good deal of 
hair it falls soon, showing that the primary hairs were 
already loosened from their papillae. This change from 
embryonal to permanent hair is a change in type, for 
the new hair is soon furnished with a medulla. After 
this there is no change in type, excepting in the devel- 
opment of new hair at puberty, though the old hairs 
constantly fall out and are replaced with new hairs. 
As the child grows older, its head, which at birth is 
usually sparsely supplied with fine hairs, becomes well 
covered with long, colored, dark hairs, and its eyebrows 
and eyelashes become more pronounced. 

Change of Hair at Puberty.— At puberty an- 
other change in the hair growth takes place, consist- 
ing in the appearance of hair upon the pubes and in 
the axillae of both sexes, and about the anus and on 
the face of males. Still later strong hairs grow in the 
nostrils and in the ears, though this growth may be 
long deferred. It is notable that there are usually no 
hairs about the anus of women. In them also, the 
axiUary hairs are generally less developed than in men, 
and often they are entirely wanting. By some ob- 
servers, indeed, it is stated that the absence of axillary 
hairs in women is the rule. As far as my observation 
extends they have almost always been present. 

Varieties of Hair Growth.— In fully developed 
adults most of the body, excepting in the regions just 
mentioned, is supplied only with colorless, fine lanugo 
hairs, but in most men and in a few women a more or 
less luxuriant growth of hair Tvdll be found upon the 
chest and extremities. In the male the pubic hair is 



PHYSIOLOGY. 35 

often continuous above with a pyramidal growth of 
hair upon the middle line of the abdomen. In women 
this is never the case, the pubic hair ending with a 
sharp horizontal line. Hair is always absent from the 
gians penis and the prepuce; from the vermilion, bor- 
der of the hps; from the labia minora; from the last 
phalanges of the fingers and toes; and from the palms 
and soles. The hair of women grows to a greater 
length than does that of men, even if the latter is un- 
cut. The hair of the scalp grows in groups, two or 
three hairs in each group, seldom as many as four. 
The hairs of each group are, according to Pincus (71), 
not all of the same length, because they are not all of 
the same age. 

Hair Centres. — The hairs are not only placed at an 
angle to the skin, but they grow from a number of 
well-defined centres. Wilson (84) has studied these 
and carefully described them as follows: '^ The hairs 
of the head radiate from the crown with a gentle 
sweep behind towards the left and in front towards 
the right. The centre for the forehead is a median 
vertical line from which the hair passes to the right 
and left, the lower border of the growth forming the 
upper half of the eyebrows. This centre is distinctly 
visible in its whole length in many newborn children. 
At the inner angle of each eye is another centre from 
which the hair radiates, the upper and inner rays as- 
cending to the line between the eyebrows, where they 
often meet those from the opposite side and form with 
them a line across the root of the nose; and the upper 
and outer rays curve along the brow and form the 
lower half of the eyebrow. The lower and outer rays 
with those of the nose, mouth and chin make a sweep 
over the cheek and side of the face. On the upper lip 
the hair grows from the nostrils outwards, and forms 
the mustache; on the lower hp there is a middle line 



S6 DISEASES OF THE HAIR AND SCALP. 

for a centre. The beard is formed by the convergence 
of two side currents which meet at the middle hne. 
On the trunk there is a centre of radiation from each 
armpit and two Imes of divergence, one of the latter 
proceeding from this point horizontally to the middle 
of the front of the chest, the other vertically along 
the side of the trunk, across the front of the hip, and 
down the inside of the thigh to the bend of the knee. 
From the armpit centre, and from the upper side of 
the horizontal hne, a broad and curved current sweeps 
upward over the upper part of the front of the chest 
and around the neck to the back. From the lower side 
of the horizontal Hne and from the vertical hne the set 
of the current is downwards and inwards, with a gen- 
tle undulation to the middle hne in front, and back- 
wards to the spine. 

'' From the armpit centre there proceeds another line 
of divergence which encircles the arm like a bracelet 
immediately below the shoulder. From the upper 
margin of this line the direction of the current is up- 
wards over the shoulder, and then backwards to the 
midline of the body. Another hne commences at this 
ring on the front of the arm, and runs in a pretty 
straight course to the cleft between the index finger 
and thumb on the back of the hand. This is the line 
of divergence of the arm. From it and from the ring, 
the stream sets at first with a curve forwards, and then 
with a curve backwards to the point of the elbow. In 
the forearm the currents sweep downwards in front, 
and upwards behind towards the point of the elbow, 
which is thus the centre of convergence. On the back 
of the hand and fingers there is an outward sweep with 
the concavity upwards. On the lower limb there are 
two vertical hues of divergence, the one being the con- 
tinuation of that of the side of the trunk, proceeding 
around the inner side of the thigh to the bend of the 



PHYSIOLOGY. 



37 



knee; the other, an undulating Hne, beginning at about 
the middle of the hip, and running down the outer side 
of the thigh and leg, and across the instep to the cleft 
between the great and second toes. A short oblique 
line connects the two vertical lines at the bend of the 
knee. '' On the front of the thigh the streams from 
the two lines converge and descend towards the knee. 
On the back they converge also at the middle line, but 
ascend toward the trunk of the body. On the leg, 
where there is but one line, the diverging currents 
sweep round the limb, and meet upon the shin, while 
on the foot they diverge with a sweep, as upon the 
back of the hand." 

Shedding of Hair. — At certain 
times of the year animals '^shed 
their coat," that is, a rapid fall of 
hair takes place and the animal's 
coat is thinned. At the same 
time with the fall of the old hair 
there is a growth of new hair and 
soon the coat is as thick as ever. 
In the human species there is, 
instead of a periodic shedding, a 
constant fall and new growth of 
hair, though at certain seasons it 
may proceed more rapidly than 
at other seasons. This is accom- 
plished in the same way as w^e 
learned when describing the em- 
bryonal hair change, namely : the 
hair loosens from its papilla and 
mounts up to the middle follicle 
region, where it remains for a 
time attached to the prickle-cell 
layer of the follicle, and grows 
there. The lower part of the follicle collapse 




Section of hair follicle show- 
ing beginning sopararion of 
hair from papilla ^.Uiin^i.) 



and the 



M DISEASES OF O^HE HAIR ANB SCALP. 

papilla grows smaller. The lower end of the old hau* 
becomes broom-hke and knob -shaped. This appearance 
is due to new cornified cells being constantly attached 
to the root as it mounts up in the folhcle. 

Beethaar. — The hak in this position is called by 
Unna (82 a) a " Beethaar, ^^ to distinguish it from the 
hair seated upon its papilla, or ^'papillary hair.^'' The 
part of the folhcle from which it grows, he names the 
' 'Haarbeet, " or ' 'hair bed. ' ' The ''beethaar' ' is always 
secondary to a papillary hair, and all hairs go through 
this stage before they fall. They are distinguished 
from papillary hairs by absence of root-sheath, want 
of cuticle and medulla in their roots, and by having 
their pigment distributed in stripes and heaps. 

The cause of the loosening and shedding of hair, 
whether at the close of their normal length of life, or on 
account of some disease, as eczema, typhus fever and the 
like, is to be sought for, according to Unna (82 a), in the 
character of the blood supply of the hair. As we have 
learned, the middle region of the hair f oUicle is supphed 
by arterial twigs from the sub-papillary circulation, 
and the papilla of the hair is nourished from little ar- 
teries from the deej)er arterial circulation of the cutis. 
Therefore the middle folhcle region must participate in 
the disturbances of the sub-papiUary circulation, while 
the papilla is relatively free from this influence. Thus 
any lessening of the nutritive supply to the papilla, or 
any increase in that from the sub-pa|)illary circulation 
to the middle follicle region must cause a preponder- 
ance of nutrition in the middle over the lower folhcle 
region. This would necessarily cause an increased 
growth of the prickle-ceU layer of the middle follicle 
region, and an increased pressure upon the hair. Then 
either the circumference of the hair cylinder would be 
lessened, or the hair itself would be pressed out of the 
folhcle and raised from the papilla. The latter is vrhat 



paYSlOLOGIY. 



30 



actually takes place. The ' ' beethaar ' ' is shoved higher* 
and higher up, so long as it remains in the middle third 
of the f olhcle, but when it reaches the unproductive 
part of the follicle, that is, just below the mouth of the 
sebaceous gland, the circulation becomes again equal- 
ized, and the hair ceasing to grow falls out. The final 
fall of the hair is hastened both by the pressure of the 
new hair from below, and by traction exerted upon it 
from above by brushing, combing, and the like. The 
loosening of the hair from its papilla begins at the 
cuticle, and proceeds from without 
inwards. 

Eegeneration of Hair. — While 
the " beethaar " is still in the middle 
foUicle region the formation of the 
new hair is under way. From the 
lower end of the old hair down to 
the papilla there stretches an epithe- 
lial process com|)osed of the old, col- 
lapsed, and greatly atrophied root- 
sheath. This enlarges, its cells 
increase, it grows downwards into 
the old hair follicle, which again 
becomes open, and shoves the old 
papilla before it. Out of this a new 
hair is formed, seated upon the old 
papifla which takes on new activity. 
The whole process is analogous to 
that which occurs in the foetus. The 
new hair mounts up in the old fol- 
licle and grows sometimes alongside 
the ' ' beethaar, ' ' but more often it 
pushes it out ahead of it. This new 
hair hves its appointed time and 
then undergoes the same fate as 
its predecessor, and thus is constantly repeated the 




Section of hair follicle 
showing hair in " beet- 
haar '^ stage, and growth 
of new hair from old 
papilla, bh =-■ beethaar ; 
/i6 = hair bed, from 
which bh grows (Unna.) 



40 DISEASES OF THE HAIR AND SCALP. 

regular normal fall and regeneration of the hair. It 
is possible that new papillae may be formed, producing 
new hairs, but the above is the usual course. 

Appearances of Hair. — The microscopical appear- 
ances of the hair will vary according to whether it is a 
lanugo hair, "beethaar," or papillary hair; or whether 
it has been plucked from the head, or has fallen of 
itself. The lanugo hairs are very fine and downy, 
colorless or very slightly colored, and contain no me- 
dulla. Their roots are small. The '^beethaar " has 
neither root-sheath, cuticle nor medulla in its root, and 
the root itself, instead of being hollow, is rounded off 
and shaped somewhat like an old-fashioned broom of 
twigs, or, it may be likened to a fir tree in shape, as 
Unna suggests. Sometimes the medulla is entirely 
absent throughout its length. These appearances are 
those commonly seen in fallen hairs. This we should 
expect from what we have already learned of their na- 
ture. The papillary hair has a long, pliable, soft root- 
end, which is bulb- shaped and hollowed out for the re- 
ception of the papilla. All the component parts of the 
hair are present in it, and the medulla can be followed 
from its root to near its point. When such a hair is 
phicked, it presents for observation in addition to the 
above, an attached piece of the root-sheath which 
makes its lower part look swollen. These are the typ- 
ical forms of hair. If the microscope is focused upon 
the surface of a hair, the edges of the cuticle cells will 
be seen as dark lines like the edges of the slates in a 
slate roof. If it is focused carefully upon the edge of 
the hair, the latter will look like the edge of a fine saw 
blade, as the edges of the cuticle cells overlap one an- 
other. If now the tube of the microscope be lowered, 
the cortical substance will come into view. It ap- 
pears like a solid body marked by short stripes of a 
darker color, which gives it the appearance of being 



PHYSIOLOGY. 41 

composed of fibres. The fibres are in reality long 
spindle- formed cells, as is learned by tracing the hair 
toward the root, when their cell form will be more 
apparent- Fine black granules are scattered about or 
gathered in heaps in its substance. These are the 
pigment granules. Lastly we meet with long, oval, 
irregularly shaped, or small, round, dark bodies lying 
between the fibres. These are air -globules. The small 
ones may be grouped and mistaken for pigment, a mis- 
take easily rectified by altering the focus, when they 
will present the changes of color dependent upon their 
optical properties, becoming lighter as we raise the tube 
of the microscope. The medulla runs through the 
centre of the hair as a dark streak. In human hair, 
when examined in water alone, the separate cells of 
which the medulla is composed, are not visible, as a 
rule. This is owing to the presence of a large amount 
of pigment and air between the cells, both of which 
have the effect of rendering the medulla dark colored 
by transmitted light. If the hair be laid in glycerine, 
the air-globules will be driven out, and the cells will 
become more apparent. The form of the medulla ceUs 
has been given in the chapter on the anatomy of the 
hair. 

Technique. — A word must be said as to the proper 
methods of examining hair. For most examinations of 
the hair, an ordinary microscope, magnifying say, 250 
diameters, is sufficient. If you have higher powers so 
much the better. The hair should be examined at first 
under a covering glass alone. Then water should be 
added and the hair again examined. To render the 
hair transparent, it should be placed in liquor potassae 
alone, or in liquor potassae and glycerine. The per- 
oxide of hydrogen acts even better than liquor potassae 
as a bleaching agent, as it bleaches the pigment and 
does not destroy the hair. Unfortunately it soon loses 



42 DISEASES OF THE HAIR AND SCALP. 

its virtues by keeping. Waldeyer (83) recommends 
a twenty per cent, solution of nitric acid for rendering 
the hair transparent. If there be much foreign mat- 
ter adherent to the hair, place the latter in a small test 
tube containing ether and shake it for some time, or 
put it in a corked bottle with ether and let it stand. 
These methods are sufficient for the proper examination 
of both healthy and diseased hair. 

Color. — The color of the hair depends upon four fac- 
tors, namely: 1. Diffused pigment. 2. Granular pig- 
ment. 3. Air contents; and 4. The superficial charac- 
ter of the hair. The cortex plays the chief part in de- 
termining the color of the hair, 1. The diffused 
pigment or essential color of the hair gives it a light - 
brown to a dark-red hue, according to its intensity. 
2. The granular pigment lies in, (Waldeyer, 83) or 
between (Unna, 82 a) the cells or fibres of the cortex, 
and, in some cases, in the cells of the medulla. It is 
found chiefly in the peripheral portion of the cortex, 
and occurs either scattered or grouped. Sometimes it 
is heaped up so thickly that the individual granules are 
indistinguishable. Its color is a shade of brown, any- 
where from a light -brown to ebony. The combinations 
of the diffused and granular pigment makes the vari- 
ous shades of color met with. The darker the hair is the 
more granular pigment it contains, but even the lightest 
of blonde hair will be found to contain some granular 
pigment. 3. The air-globules are generally in the outer 
layers of the cortex. Viewed by direct light they ap- 
pear under the microscope as brilliant points; by trans- 
mitted light they appear black. 4. By the superficial 
character of the hair is meant whether it is smooth or 
rough. These two last factors influence the color of 
the hair on account of a law in optics, namely : Every 
body appears white in white daylight if it reflects the 
white light to all sides. If the surface of the hair be 



PHYSIOLOGY. 43 

uneven, and there are many little particles of air in the 
cortex and medulla, the light will be thus reflected 
and the color of the hair will be, therefore, more or 
less white, the tone being modified by the amount of 
pigment present in the cortex. A hair containing pig- 
ment never appears quite white, even if air be present, 
but some shade of gray. If there be no air present, or 
the pigment is in excess, the hair will be more or less 
purely of the color of the pigment. The most univer- 
sal color of hair is dark brown or black. 

Pigment.— The source of the pigment is not yet sat- 
isfactorily settled. It is derived, without doubt, from 
the coloring matter of the blood, as is all the pigment 
of the body. Ehrmann (100 and 101) of Vienna, 
pubhshed, in the years 1884, 1885 and 1886, some ex- 
ceedingly interesting and valuable observations upon 
the formation of pigment in the skin and hair. His 
studies were made in the beginning upon frogs and 
salamanders; later upon the skin of dogs and men. 
He has found that the pigment is produced only in the 
corium, in parts immediately surrounding the blood- 
vessels, and that cell activity is absolutely essential 
thereto. From the corium it reaches the epidermis 
through protoplasmic movement. The pigment cells 
in men are round or oval, with short or few branches 
or prolongations. They are in the basal cells of the 
epidermis and send their prolongations downwards into 
the corium, to connect with the pigment-carrying cells 
of that part. The latter are not a peculiar species of 
cells, but true connective- tissue cells. 

But, we are interested now more especially mth the 
pigment of the hair. Pigment-carrying cells are found 
in the hair papilla, which are large in its neck and 
lower parts, and small in its top. As yet no branches 
have been observed to tJiese cells. The pigment cells 
proper he for the most part in the bases of the mat- 



4-1 DISEASES OF THE HAIR AND SCALP. 

rices, entirely included in them, and touch the boundary 
of the papilla only with one side of their circumfer- 
ence. Their branches pass only upwards between the 
cells of the matrix of the cortex up to the point where 
these begin to undergo cornification. The cells them- 
selves of the cortex are devoid of pigment. Further 
up in the hair matrix, the branches of the pigment 
cells form a net-work, and the cortical cells of the third 
or fourth row are in close connection with this net- 
work, and themselves contain pigment. 

Life Phenomena. — The length of life of the hair 
varies with the age, sex, character of hair, and indivi- 
dual pecuharity. Each hair has its determined length 
of life, and this is not the same for every hair of the 
same sort. What may be the circumstances that de- 
termine the period of its existence is not known. The 
lifetime of the eyelashes has been determined by 
Mahly as one hundred and thirty five days. PiNCUS 
(71) says that the period of hair growth on the human 
head is from two to six years. Hair is said to grow 
faster by day than by night, and in the warm weather 
rather than in the cold. Shaving and cutting the hair 
certainly make it coarser, and may be, stimulate its 
growth. The average length of the hair of the head 
in women of the Anglo-Saxon race is from eighteen to 
twenty-four inches, when left uncut. Exceptionally 
it may grow to thirty-six or even fifty inches or more 
in length. The hair of men of the same race has an 
average length of six to eight inches; but custom de- 
manding that it be cut from time to time, it is rarely 
seen of this length. The hair of each individual 
has its own determinate length, and the hair of men, 
even if left uncut, will not grow as long as that of 
women. The rate of growth, specially in young women, 
is from 2 to 5 mm. during each ten days after first 
piercing the skin. When it reaches a length of ten to 



PHYSIOLOGY. 45 

fourteen inches its rate of growth is reduced one half; 
and later towards the end of its normal life its increase 
is hardly perceptible. The short, stiff hairs, as of the 
eyebrows, are from J to 1 inch long. 

Hairs, without their papillae, have been transplanted 
and become fixed on granulating wound surfaces and 
on the iris. I do not know that they have actually 
taken root and grown there. 

The average number of hairs to the square inch 
is given by Wilson (84) as, on the scalp, l,OuO. 
WiTHOF (83) found on a man in one quarter of a 
square inch of the crown of the head, 293 hairs; 
occiput, 225; anterior part of the head, 211; chin, 39; 
pubes, 34; forearm, 23; back of the hand, 19; anterior 
surface of the thigh, 13. Wilson (84) calculates that 
there are 120,000 hairs upon the head of an adult. As 
a rule the finer the hairs, the thicker they will stand on 
the head. 

The diameter of the hair varies with its color and 
location, and with the age and sex of the individual. 
Wilson (84) found that flaxen hair was the finest, and 
black hair the coarsest; that the hairs of the beard 
and whiskers were coarser than those of the breast and 
eyebrows, and then in order of decreasing diameter came 
those of the eyelashes and armpit, of the head, of the 
thigh, and of the leg, the latter being finest. The finest 
hairs of the scalp in the Anglo-Saxon race are from 
TTiTo to Foo in., while the coarsest are from ^-g to yfo 
in. in diameter. The head hair of a woman is some- 
what coarser than that of a man, the diameter of the 
former being from ^Jo to ^^ in. ; that of the latter 
from -^j to ^ in. As a general rule, tlie hair of chil 
dren is finer than that of adults, ranging from j\-^ to 
4 Jo in. in diameter. Even on the same head tliei-e is a 
great diversity in the diameter of different hairs, and 
individual hairs are not of the same thickness through- 



46 DISEASES OF THE HAIR AND SCALP. 

out. As stated in the first chapter (p. 21) the contour 
of the hair is circular, oval or flattened. Whether a 
hair is to be curly or straight is largely dependent upon 
its contour; the more oval or flattened it is, the more it 
will be curled. The curhness is influenced, also, by 
the condition of the atmosphere; naturally curled hair 
becomes more curled when the air is surcharged with 
moisture, and less so in dry weather. But artificially 
curled hair always loses its curl in damp weather. 

Eace Differences. — Ethnographical classifications 
have been founded upon the evident differences exist - 
ing in the hair of different races of men. We are all 
familiar with differences of color, as between the black 
hair of the Negro, and the flaxen hair of the Saxon race; 
and of form, as between the close curled hair of the 
Negro, and the long straight hair of the American In- 
dian. As marked differences between races exist in 
the contour of the hair, in the manner of its grouping, 
etc. But a discussion of these matters of classification 
is foreign to our purpose, and we will content ourselves 
with the mere statement of the fact. 

Physical Peculiarities. — It has already been stated 
that the curliness of the hair is influenced by the 
moisture of the atmosphere. This is because the hair 
is hygroscopic, absorbs moisture very readily from the 
atmosphere, and becomes lengthened, as well as more 
rounded. Hair is also elastic, and is capable of being 
stretched from one-fifth to one-third of its normal 
length. When the tension is removed it will retract 
to nearly but not quite its original length. It possesses a 
considerable amount of strength, a good healthy adult 
hair being capable of sustaining a weight of from two 
to four ounces without breaking. The qualities of elas- 
ticity and resistance are mainly located in the fibrous 
portion or cortex of the hair. Hair is strongly elec+ric 
by friction, particularly in cold and dry weather. Its 



PHYSIOLOGY. 47 

electricity may readily be shown by passing a rubber 
comb through the long hair of a woman, when a slight 
crackhng sound will be heard In peculiarly susceptible 
individuals the hair will stand almost straight out from 
the head under this electrical stimulus. The electricity 
of the hair is negative. 

Chemical Constitution. — The chemical constitu- 
tion of the hair, as given by Waldeyer (83) from sev- 
eral recent analyses, is as follows: One hundred parts 
of dry hair contain from fV to yV part of incombustible 
material. This contains 23 per cent, of alkaline sul- 
phates, 2 to 10 per cent, oxide of iron, and 40 per cent. 
siHca. Dark hair contains somewhat more iron. The 
analysis of the hair substance shows it to be composed 
of carbon, 50; hydrogen, 6.36; nitrogen, 17.14; oxygen, 
20.85; sulphur, 5. The hair is said to contain a cer- 
tain proportion of an oily substance, the color of which 
varies with that of the hair. The proportions of the 
chemical constituents vary with the color of the hair. 
Thus, fair hair contains least carbon and hydrogen and 
most oxygen and sulphur; brown hair gives the lar- 
gest proportion of carbon and the smallest quantity of 
oxygen and sulphur; white hair of the aged contains 
a considerable amount of bone earth or phosphate of 
lime. The quantity of nitrogen remains the same in 
a 

Uses of Hair. — The uses of the hair are fourfold: 1. 
As a preservative of heat. 2 As a protective agency. 
3. As an organ of touch. 4. As a promoter of beauty. 
(1.) As the hair is a bad conductor it serves to preserve 
the hea,t of the body. When one is exposed either to ex- 
cessive heat or cold the hair is apt to grow more luxuri- 
antly. (2.) The hair of the head forms a thick elastic 
cushion, and is thus an admirable defence to the skull 
against blows and falls. The pubic hair in like manner 
acts as a cushion during coitus. The eyebrows are a de- 



48 DISEASES OF THE HAIR AND SCALP. 

fence to the eye against blows, and turn the perspiration 
to the outside of the eye- socket, thus preventing its gain- 
ing access to the eye. The eyelashes catch flying par- 
ticles of dust; the hairs of the nostrils and ears prevent 
insects from crawling into the cavities which they pro- 
tect, as well as guard against the entrance of other for- 
eign substances; the mustache acts as a respirator; and 
the beard protects the larynx from the action of cold. 
(3.) Parts furnished with hair are more sensitive than 
are those without it. This is because the hair, being 
planted at an angle to the skin, acts as a lever on being 
touched, shoves to one side the hair-follicle, and thus 
causes a slight irritation of the neighboring cutaneous 
nerves. This sense of touch in man is but little develop- 
ed. (4.) Of the hair as a promoter of beauty, httle need 
be said, as it will be conceded by all that the hair is 
an adornment. 

Uses of the Sebaceous Glands. — The sebaceous 
■glands furnish an oily secretion to the hair which ren- 
ders it pHable and soft, and gives it lustre. This secre- 
tion is a constant one in health, and is the result of a 
fatty degeneration of the hning cells of the glands, 
which slowly fill up with the oily matter, burst, and 
discharge their contents. As the sebaceous glands 
empty into the hair-follicles in their upper third, they 
are admirably located for lubricating the hair just be 
fore its exit into the outer air. The oil is upon the out 
side of the hair and also v^thin it. It reaches the in- 
terior of the hair by capillary attraction, as will be 
readily understood by referring to the anatomy of the 
hair, and noting its fibrillar construction and the spaces 
between its fibres. Pincus believes that the capillary 
attraction is, to a certain extent, assisted by the pres- 
sure exerted upon the hair in the part of the follicle, 
just above the entrance of the sebaceous gland, its nar- 
rowest part or neck, the diameter not being large 



PHYSIOLOGY. 49 

enough to admit of the escape of the hair and the se- 
baceous matter at the same time, without considerable 
squeezing, so that the sebaceous matter is pressed into 
the hair. 

Muscles. ^ — The arrectores pilorum muscles pass 
under and around the sebaceous glands, to be inserted 
into the hair-follicle. By their contraction they 
straighten the direction of the hair bulb, and, in conse- 
quence, erect the point of the hair, literally causing the 
hair to stand on end. This function is observed in 
man chiefly in the occurrence of "goose flesh," from 
the action of cold. The contraction of these muscles 
further aids, though to a slight extent, the emptying 
of the sebaceous glands. 



CHAPTEE III. 

THE HYGIENE OF THE HAIR. 

Attention to the care of the hair and the hairy 
scalp is of special importance to those who belong to 
famihes in which premature baldness is hereditary, 
and it can not be given too early. We should, there- 
fore, instruct the parents as to the importance of giv- 
ing attention to their children's heads, so that the 
matter may not be delayed too long, and the hair fall 
out when it is too late to stop it. Dandruff is regarded 
by most people as merely an annoyance, and, if not 
excessive, is neglected. If we could convince the laity 
that dandruff is the chief cause of baldness, they would 
eagerly seek relief, the disease could be early checked, 
and the day of hair-fall very much delayed. The care 
of the hair is important, not only to those with an in- 
herited tendency to baldness, but to all who wish to 
preserve their hair in good condition, and, if properly 
attended to, it will be a prophylactic, not only to dis- 
eases of the hah' proper, but also to parasitic troubles 
of all sorts. It is true that this demands the expendi- 
ture of a certain amount of time, but it is time v/ell 
expended, though, I must confess, often greatly be- 
grudged by male patients. 

The hygiene of the hair and scalp consists in the 
proper use of the shampoo; in brushing and comb- 
ing; in arranging the hair; in the exposure of the 
hair to air and light; in cutting and shaving it; and 
in the use of pomades. We should watch over the 
hair from earliest infancy, and instruct our patients as 
carefully in regard to its hygiene as we should do in 
regard to matters of general hygiene. 



THE HYGIENE OF THE HAIR. HI 

Shampoo. — The first attention that the hair demands 
is the ridding of the scalp of the newborn child of the 
vernix caseosa. This is the first shampoo, and should 
be more carefully performed than any subsequent one. 
Improper management at this time may entail endless 
worry to the mother and a great deal of suffering to 
the child, as it is exceedingly likely to set up an in- 
flammation of the scalp. The child is born covered 
with a fatty matter called the vernix caseosa, which 
is often very thick upon the scalp. Steps are to be 
taken at once for its removal, which must be effected 
with the greatest care, and with the avoidance of all 
force. To this end the scalp is to be saturated with 
sweet almond oil, which is the most elegant means; or 
with oHve oil or vaseline. (It is preferable to use these 
in their natural state, but if desired, there is no objec- 
tion to perfuming them with a few drops of the oil of 
bergamot, wintergreen, or the like.) The nurse should 
do this immediately after she has washed the child's 
face and eyes. Then after the body has been bathed 
and the infant dressed, she should wash the head with 
plenty of warm water and soap, such as pure castile 
or glycerine soap, either solid or Hquid. This should be 
done very gently, and if the vernix caseosa is not readily 
removed, she should re-apply the oil and wait until the 
next day, when it will be easily washed off. Should it 
still prove obstinate, let her patiently repeat the process 
until it comes off. In no case should the fine toothed 
comb be used. For some weeks the infant's scalp should 
be lightly oiled, as this wiU prevent any accumulation of 
sebaceous matter, and protect the tender skin from in- 
jury from atmospheric causes until the hair grows, 
care being taken to wash the head daily to prevent the 
oil from becoming rancid. When the hair is grown 
the scalp need not be so often oiled, nor should it be 
washed more than once or twice a week. 



52 bisiiASES or the hair and scaLI^. 

In children and adults, the scalp should be kept clean 
so as to avoid stopping up the hair follicles with foreign 
matter, and to prevent any irritation of the scalp, which 
its presence might cause. This is accomplished by the 
systematic use of the shampoo followed by careful dry- 
ing, and the application of some oily substance to the 
scalp. It may be given as a rule, that a shampoo every 
second to fourth week is sufficient for the scalp of those 
who are not exposed to more than the usual amount 
of dust; while those who are so exposed should sham- 
poo their heads every week or two. The practice of 
daily sousing the head with cold water, as is very 
commonly done by men, is pernicious, not because the 
water itself is harmful, but because the scalp is not 
properly dried afterwards; no oil is applied to take the 
place of the oil that has been removed by the water, 
the wet hair cannot be thoroughly brushed, and soon 
it gets into a condition of dryness and brittleness. 
Women avoid getting their hair wet, and this may be 
one reason why they are less often bald. 

The proper manner of shampooing the head is as 
foUows: Choose some good soap, such as Pears' ^' Gly- 
cerine Soap," Sarg's "Liquid Glycerine Soap," pure 
Castile soap, the tincture of green soap, or the tincture 
of prepared olive soap, and with plenty of warm water 
make a good lather on the head, and rub the head vig- 
orously with the fingers, or with a rather stiff, long 
bristled brush. If the scalp is very sensitive to irri- 
tants, borax and water may be used instead of soap, 
or a mixture composed of the yolks of three eggs beaten 
up in a pint of lime water. When the head has been 
thoroughly shampooed, wash out the lather with a 
copious supply of warm water, or, where practicable, 
with alternate douches of warm and cold water, and 
then dry both scalp and hair with a good bath towel. 
When all is dry, rub on the scalp, not on the hair, a 



The hygiene of the it air. 5S 

small quantity of some unctuous substance, such as 
sweet almond oil or vaseline. Care must be used in 
drying the hair, specially in women, who should sit 
before an open fire, or in the surdight when doing it, and 
who should not dress the hair until it is perfectly dry. 
To oil the scalp, the hair should be parted and the oi] 
rubbed in along the part, then another part made, an 
the operation repeated, and so on till the whole scaly 
gone over. Should there be an excess of oil upon 
hair, a condition which is disagreeable to many, it maj 
be removed readily by pulling the hair between the 
folds of a damp towel moistened with ether, chloro- 
form, or cologne water. 

Brushes and Brushing.— Of far more importance 
than shampooing is the use of the brush and comb, 
and much more care should be given to the selection 
and use of these common toilet articles than is usually 
bestowed. Too often they are badly made, and gener- 
ally, specially with men, they are used in a very per- 
functory manner. The brush which is to be used upon 
an infant's head should have long, soft bristles, so as 
not to scratch or irritate the tender scalp, and should 
be employed simply in smoothing and polishing the 
hair. For young children whose hair is well grown, a 
stiff er brush is necessary, and for adults, two brushes 
should be used, a stiff one and a soft one. A properly 
made brush has its bristles placed in little clumps or 
groups in such a manner that the middle bristles of 
each group are longer than those of the periphery. 
The bristles are well set into the back of the brush and 
the groups are wide apart. Most of the brushes met 
with in the shops are made with the bristles all of the 
same length and the groups close together so as to look 
pretty, but not to perform their proper function. The 
stiff brush should be used systematically in the morn- 
ing and with considerable vigor, so as to produce a feel- 



54 DISEASES OF THE HAIR AND SCALP. 

ing of warmth in the scalp and to brush out all parti- 
cles of dandruff and foreign matter lodged in the hair. 
Every part of the scalp should be gone over with the 
stiff brush, and then it should be laid aside for the rest 
of the day, and the soft one used to assist the comb in 
parting the hair, and to give smoothness and gloss to 
it. The stiffness of the brush and the vigor of its em- 
ployment must vary with the tenderness of the scalp, 
and in no case should be sufficient to cause a f eehng of 
soreness. Were brushing performed in the manner 
indicated, the hair would lie properly without the aid 
of water or pomades, excepting of course in cases of 
mal-position of the hair, as in the so-called cow-Hck, 
or where the hair is unnaturally stiff. 

Combs and Combing. — The comb is next in impor- 
tance to the brush, its office being to open up the hair 
so that the brush may reach all parts of the scalp, to 
part the hair, and to disentangle snarls. A properly 
made comb has long, thick, wide, perfectly smooth 
teeth, with well-rounded ends, and set wide apart. In 
choosing a comb it should be held up to the hght, and 
discarded if any roughness or irregularities are found 
in the surfaces of its teeth, for such a comb would catch 
and tear the hair. Combs are usually made with a 
coarse and a fine half, and there is no objection to this 
arrangement if the fine part is used only to disentangle 
the hair. No attempt should be made to pick off crusts 
from the scalp with the comb. It should be used only 
as an assistant to the brush, and always with it in the 
systematic morning brushing. No comb should touch 
an infant's scalp, and the fine-toothed comb should be 
rigorously excluded from the toilet case. It is a dan- 
gerous instrument, the cause of many a case of eczema, 
and only of use in removing the ova of lice from the 
hair. Above aU things, the tender scalp of the infant 
should be spared from its damaging effects. 



THE HYGIENE OP THE HAIR. 5o 

Dressing of the Hair of Women. — Now we come 
to a place in the discussion of the hygiene of the hair 
in which fashion often interferes. Examination of old 
fashion plates and portraits will show how women and 
men have tortured the hair, twisting it into all sorts of 
shapes, and smothering it under wigs, false hair and 
powder. Happily, at present, the hair is worn more 
simply, but still the crimping or the curling iron is too 
much used, and the hair is pulled and dragged upon 
too much in adapting it to the varying demands of the 
hair-dresser. Sooner or later nature is apt to rebel 
against fashion, and the hair grows less luxuriantly or 
falls out. The simplest mode of wearing the hair is 
the best. It should be combed and brushed smoothly 
back upon the top of the head, either parted or not as 
is most becoming, and gathered into a loose braid or 
coil at the back of the head. Girls should wear a pend- 
ant braid; and women whose hair is grown and who 
gather the hair into a coil, should use large hairpins 
in fastening it, preferably of rubber or bone, with abso- 
lutely smooth surfaces. In doing up the hair care 
should be taken not to drag upon, it; and drawing it 
into unnatural positions, such as pulling the hair from 
the back of the head over forwards to near the fore- 
head, should be avoided. If a woman's hair curls 
naturally, she should be thankful for the favor therein 
bestowed, but should it not curl of itself, she should 
not attempt to make it curl by singeing and squeezing 
it between hot irons, scorching it over a hot pipe -stem, 
or twisting it up tightly in curl papers. 

Wigs, Hats, etc. — The hair requires for its growth, 
and for the maintenance of its health, both air and sun- 
light, though not necessarily exposure to the direct 
rays of the sun. It is difficult to prove that wearing 
of the hat constantly is a cause of baldness, but there 
are many indications that such is the case, and it is 



^6 ' WSEASES OF THE HAIR AND SCALP. 

well to avoid keei3ing the head covered with an unven- 
tilated hat. If the occupation compels one to be out 
of doors most of the time, or exposed to draughts so 
that a hat or cap must be worn, it should be well ven- 
tilated, so that the heat from the head may not become 
confined, and the hair more or less sweated. The sub- 
ject of hats as a cause of baldness will be treated of 
more fully under Chapter VI., upon Alopecia. The 
wearing of wigs and false hair is bad for whatever hair 
remains, and should not be practiced. The absurd 
'' water-falls " of a few years ago, and the no less ridi- 
culous powdered wigs of old times are happily things 
of the past, and should never be revived. If a woman's 
hair is short and scanty, it is better to wear it cut short, 
and endeavor to stimulate its growth by attention to 
the scalp, than by wearing false braids to assume a 
beauty which she has not. Wigs heat the head and 
sweat the hair. False hair by its weight drags upon 
the feeble hair it is designed to fortify. 

The wearing of night-caps was once a custom, 
founded upon the need of keeping the head warm in 
the inadequately heated bedrooms of our ancestors. 
With the improvement in house building and heating, 
the custom has passed away, and should not be re- 
vived, as it excludes the air from the hair continuously 
for a good part of the day. Of course where there is 
no hair, and the bald individual is sensitive to the cold, 
there can be no objection to keeping the head covered 
with a wig by day and a cap by night. 

Hair Cutting. — AU men wear the hair short, and 
employ a barber at varying intervals according to their 
fancy. As far as the health of the hair is concerned, 
it is immaterial whether it is cut at longer or shorter 
intervals, but it is essential that it should be well cut, 
and a good barber is desirable. It should never be 
^^ shingled," as the barbers term an operation which 



THE HYGIENE OF THE HAIR. 57 

consists in cutting the hair by a to-and-fro motion of 
the shears, as this tears and roughens the hair. The 
hair of children, whether they be boys or girls, should 
be kept cut short until the seventh or eighth year of 
age, as the growing hair is a drain upon the nutrition 
of the body, and at this time of life all the nutritive 
forces should be expended in the growth of muscle and 
bone. The hair of a girl after she has reached her 
eighth year should be allowed to grow, as the less the 
hair is cut the finer it is. But should the girl be so 
situated that her scalp and hair can not be properly 
cared for, then she will have a better chance for a good 
head of hair in later life if it is cut when she is young. 
The hair of women is seldom worn short, although of 
late some young women have seen fit to adopt the style 
of wearing the hair like a man, along with his coat and 
waist -coat. It is quite common for the long hair of 
women to he split at the point. This should be looked 
for, and if found, the hair should be cut above the 
cleft. All ragged ends should be lopped off, and all 
weak hairs should be cut off near the head to improve 
their strength. 

Shaving. — The shaving of the beard is regulated 
largely by fashion. Physiologically it is best not to 
shave, for if we do, we rob ourselves of a useful protec- 
tion to the throat and lungs. As shaving makes the 
hair grow coarser, it is often resorted to very early by 
the youth, for the purpose of rendering the down of 
the lip or cheek more apparent. It would be better to 
endure the down for a time, as the growth of an ele- 
gant soft beard would be the reward. If one must 
shave, he should do it himself, and see that his razors 
are kept sharp. He should shave himself, so as to 
avoid the risk of infection with I'ingworm of the beard. 
If his razors are dull, he is apt to set up an inflannna- 
tion of the hair-folHcles or skin. For shaving, a mild 



58 DISEASES OF THE HAIR AND SCALP. 

soap that forms a thick lather should be used, and after 
the operation, especially in cold or windy weather, the 
face should be powdered with simple rice flour or fine 
corn- starch. 

Pomades. — Punch's advice to a man about to marry 
is equally applicable to the use of pomades. It was: 
"Don't." Their regular use upon the healthy scalp 
is uncalled for. They are dirty, soon become rancid, 
and emit a foul odor, unless this is covered by some 
strong perfume, and they soil whatever the wearer's 
head comes in contact with. If the rules already given 
are followed, the hair will be smooth and have suffi- 
cient lustre for beauty without pomades. If the scalp 
is diseased, the proper remedies should be apphed. In 
the following pages it will be indicated when and what 
pomades should be used. Most of the greases advertised 
for the cure or prevention of baldness or grayness are 
useless, and some harmful. The powers of some have 
been vaunted upon grounds that are rather absurd, as 
for instance bear's grease, because the bear is weU cov- 
ered with hair. " Bandohne " and the like sticky sub- 
stances, as well as hair dyes, should not be used, as 
the former is bad for the hair, and the latter are not 
infrequently followed by loss of health from the poisons 
they contain. 

In some cases the hair becomes matted together in 
a tangled mass, especially that of women during pro- 
longed iUness. From whatever cause arising, care and 
patience wiU usually enable the mass to be unravelled 
and the hair saved. To do this it must be attacked a 
httle at a time with oil, soap and water, and the fin- 
gers, and picked apart and combed straight. By proper 
care the condition is avoidable in most cases. It would 
be very exceptional when a patient could not bear the 
combing of the hair with a coarse comb once a day, 
followed by plaiting it into one or two plaits. When 



THE HYGIENE OF THE HAIR 59 

this is done gently and quietly it will prove refreshing, 
and will prevent any trouble with the hair during con- 
valescence. If it cannot be done, then it is best to cut 
off the hair to one half or one third of its length, so 
that it will be less liable to tangle. 

As the hair sympathizes with the general health of 
the body, the latter should be maintained in good 
condition by a wise conformity to the laws of 
health. By the proper combination of the hygiene 
of the body with that of the hair, it is possible 
for even one who is predisposed to premature 
baldness to ward off the evil day for years; and 
one who comes of a strong-haired family should, 
as a rule, not become bald or have any essential disease 
of the hair. 



1 



PAET II. 

THE ESSENTIAL DISEASES OF THE HAIR. 

Canities. — Discolorations. — Alopecia. — Alopecia 

Areata. — Atrophia Pilorum Propria. — 

Hypertrichosis.— Trichiasis. — 

Sycosis. 



CHAPTEE TV. 

CANITIES, OR GRAYNESS OF THE HAIR. 

Synonyms. — Trichonosis cana; Trichonosis discolor; 
Poliothriox poliosis; Trichonosis poliosis; Trichosis 
poliosis; Spilosis poliosis; Poliotes; Whiteness of the 
hair; Blanching of the hair; Atrophy of the hair -pig- 
ment. 

Canities may be congenital or acquired; partial or 
complete; sudden or slow in its onset. The most com- 
mon form is the acquired, which usually begins as a 
graying of a few hairs, and proceeds more or less slow- 
ly till it affects all the hair of the head and face. 

Congenital Canities usually occurs in the form of 
tufts, sometimes in round patches, the more or less 
white hair showing conspicuously among the normally 
colored mass. These cases are rare, but in some fami- 
lies are hereditary, a white tuft of hair occurring in a 
large number of its members. Among the cases of this 
sort is that reported by Godlee (103) who, in 1884, met 
with a girl six years of age, who had a patch of white 
hair growing from a white patch of scalp. The child's 
mother had a precisely similar patch, and stated that 
it had occurred in two of her sisters, in one brother, in 
her father and paternal grandfather. One of her sis- 
ters had four children, all of them girls, similarly af- 
fected. When the whiteness of the hair is general, it 
is associated with delicate pink skin and eyes, and is 
part of that condition known as albinism. 

Acquired Canities may be premature or senile. Most 
often grayness does not begin before the thirty-fifth or 
fortieth year of age. If it occurs before that time, it may 



64 DISEASES OF THE HAIR AND SCALP. 

be considered, for convenience, as premature; if after 
that time, as senile. Both forms are exceedingly com- 
mon, many persons becoming quite gray between the 
twentieth and twenty-fifth year, while it is exceptional 
for any one to attain the age of fifty without more or less 
gray hair on the head. There are so many variations 
in the manner of turning gray, that it is hard to give 
a definite rule; but the hair of the temples usually 
changes its color first, then, after a greater or less 
length of time, that of the vertex and whole head. 
Sometimes the beard is the first to whiten, but it more 
commonly follows that of the head. The hair of the 
pubes and the axillae is the last to turn gray, and often 
it escapes entirely. When the process is due to some 
passing cause it may cease upon the removal of the 
cause, and cases of normally colored hair growing in 
after the fall of the white hair have been noted. A 
very rare instance of this has been reported to me by Dr. 
J. W. Warner of this city. The case was well known 
to him, and was one of relapsing canities affecting a 
gentleman living in Sharon, Conn. This gentleman's 
hair and beard changed from black to white, and back 
again three times in thirty years. The change from 
black to white was always rapid, while that in the re- 
verse direction was slow, taking some five years for 
completion. Then would come a pause of some years 
when the color was normal, and then it would become 
white again. During all the thirty years his health 
was good, he was able to attend to an active out-of- 
door business, and never used any hair dye. Isdell 
(104) has reported the case of his father, who, 
in 1861, and when sixty-two years of age, had per- 
fectly gray hair on his head and beard, while in 1882, 
when he died at the age of eighty -three, his hair was 
of its natural dark color with the exception of a few 
gray h9;irs on the temples, This case i^ of the same 



CANITIES, OR GRAYKESS Of THE HAIR. 65 

order as those of a new growth of teeth and hair in 
extreme old age. While instances of white hair be- 
coming normal in color again are rare, it is not un- 
common for the grayness to remain partial and appar- 
ently stationary for a number of years. Generally, 
however, grayness is progressive and permanent, 
whether it is premature or senile. 

The hair in canities is usually unchanged except- 
ing in color, but it may be drier, stiifer, and 
even coarser than normal. As a rule, there is no 
change in the color of the scalp. Where we find 
gray tufts upon pale yellow patches of scalp, the 
disease is rather vitiligo than canities. The change 
in the color of the hair takes place at its root first, and 
not, as has been maintained, at its point. It usually 
changes to gray on account of the mixture of the es- 
sential color of the hair with the whiteness produced 
by absence of pigment and the presence of air. Ex- 
ceptionally, hairs are met with whose point and root 
are white, and the intermediary part normal in color; 
or the point and root normal, and the intermediary part 
white. Gradually as the pigment becomes more and 
more deficient, the white color gains the ascendency, 
the whole hair is blanched, and finally becomes of a 
yellowish or snowy white. The darker the original 
color of the hair, the more prone it is to turn gray; 
brunettes are more often gray than blondes, and be- 
come so earlier in life. Canities may exist for years 
without alopecia, as there is no direct connection be- 
tween them. In the senile form, however, alopecia is 
apt to come on as another senile change, and Landois 
states that incipient baldness usually foUows senile ca- 
nities in from one to five years Men are more often 
affected with canities than are women. 

Sudden change of color ov the hair from its normal hue 
to perfect white,has been i'^o -a -dt rr.itheiitiCvited to allow 
3 



66 Diseases of the hair and scalp. 

of a doubt as to its occurrence, though its possibihty has 
been denied by good authorities, who have questioned 
the correctness of the observations reported. But both 
medical and lay history record many instances of the 
phenomenon, and several recently reported cases dem- 
onstrate its possibihty. Thus Landois (108), in 1886, 
reported a case observed by himself, occurring in the 
person of a man thirty -five years of age, who was ad- 
mitted into the hospital suffering with dehrium tre- 
mens. His dehrium took the form of great terror 
whenever any one approached him. On admission his 
hair was of blonde hue, and remained so up to the 
evening of the third day. On the morning of the 
fourth day, the hair both of the beard and scalp was 
noticed to have become gray. Some of the hairs were 
white from root to point, some only at their points, 
some only at their roots, while some were blonde and 
white at different points. Another interesting case of 
this kind was reported by Raymond (IIG) in 1882. The 
patient was a French woman, thirty -eight years old, 
with black hair. She was of a nervous and impres- 
sionable temperament. In July, 1881, she was greatly 
affected on account of parting' with her son, and for 
about six weeks she could not sleep. In January, 1882, 
she was utterly prostrated by the loss of a large sum 
of money on the Bourse, and since then had been ex- 
ceedingly nervous, finding it impossible to remain quiet 
in any position for any length of time. She lost her 
appetite, could not sleep, and had pains in various 
parts of her body, especially in her head, shoulders and 
tibiae. These pains were of two characters, the one 
constant, and the other neuralgic and lancinating. On 
the head and face there were various painful points. 
When she received the news of her loss she was men- 
struating, and the flow was immediately suppressed. 
On January 31st she had a terrible attack of neuralgia. 



(JAI^itlES, OR GRAYNESS OF THE HAIR. 67 

By two o'clock in the morning of February 1st, her 
hair was of normal color, at seven o'clock it was al- 
most . completely discolored. Upon the sides of the 
head the color was preserved in part; upon the upper 
portion most of the hair was fiery red. The remainder 
of the hair had become completely white. The hair 
on the rest of the body was unaffected. The pains 
still continued. On the next day most of the red hair 
had become white, and was rapidly falling. In fifteen 
days nearly all the hair had fallen out, only a few hairs 
remaining on the lateral and occipital regions. Up to 
the thirtieth of March there was no return of the hair, 
nor of the color to those remaining. 

EiNGED Hair.— Ringed hair is an anomalous variety 
of blanching of the hair, in which the affected hairs 
are marked by alternate rings, one ring having the 
normal color, and the next one being white. This dis- 
ease is of very rare occurrence, and but few cases have 
been reported. Wilson (122), in 1867, reported a case 
of this kind, which, I believe, is the first on record. The 
patient was a boy between seven and eight years of 
age; the disease was first noticed when he was between 
two and three years old, and was increasing. It af- 
fected only the head. The hair-cylinder was uniform, 
the brown or normal segments measured ^V of an inch 
in length, and the white segments were about one half 
as long. 

Another case was reported by Lesser (110) in 
1885. This occurred also in a child four and a half 
years old, othervdse healthy. It was born entirely 
vdthout hair, excepting its eyebrows, which were nor- 
mal. Soon after birth the scalp presented the appear- 
ance of goose flesh, which still remains. The hair be- 
gan to grow by the second year. At time of presen- 
tation of the case, there was observed a lichen pilaris 
appearance along the border of the hair, on the neck 



6§ biSEASfeS of THE! JlAiR A^ ^6AtJP. 

and temples. The hair of the whole head was extra- 
ordinarily short, measuring even after two years 
growth, from 1 to 9 cm. ; it was dry and brittle and 
inclined to tangle. The color was brown. The longer 
hairs were normal. The short hairs were ringed in 
great part, and microscopically showed alternate swell- 
ings and contractions of the shaft, the former being 
spindle-shaped and forming the light or white ring by 
direct light. The distance between the contractions 
averaged 0.6 cm. On a great number of the ringed 
hairs there were appearances characteristic of Trichor- 
rexis nodosa, to which disease this case may perhaps 
more properly belong, as W. G. Smith (303) has, in 18Y9, 
reported a case of the latter disease in which the same 
appearances were present. 

Etiology and Pathology. — Senile canities and 
most cases of the premature or presenile form, are due 
to an obscure change in the nutrition of the hair-papil- 
la, which interferes with the production of pigment. 
Whatever the nature of the change may be, only this 
function of the papilla seems to be interfered with, as 
the hair-forming function is in normal activity, judging 
from the fact that the hair in many cases is in full 
vigor. Ehrmann (101), on the other hand, holds that 
the pigment is formed in the papilla, but fails to reach 
the hair on account of absence of certain cells in the 
hair-root, which he believes are the active agents in 
transferring the pigment from the papilla to the hair. 
His views are given more fully in the chapter on Phy- 
siology of the Hair. According to Pincus (113), in the 
beginning of canities the pigment slowly leaves the 
middle layers of the papilla and remains only in the 
external layers. With the increase of the canities, 
only a portion of the external layers of the papilla will 
produce pigment, which in straight hair will run in 
streaks parallel to the long axis, and in curly hair wiP 



6A5CiT}ES, OR GRA'^NESS OF THE HAIR. 60 

run in a spiral. The blending of the colored and un- 
colored streaks will produce the gray color, which will 
gradually change to white as the pigment is less and 
less produced. 

Our study of the physiology of the hair, has 
taught us that the color of the hair (see page 42) 
is very much influenced by the amount of air con- 
tained in the cortex. In cases of sudden blanch- 
ing of the hair, the change of color is dependent upon 
the formation of air-bubbles between the hair-cells of 
the cortex, its presence rendering the cortical sub- 
stance opaque and obscuring the color of the pigment. 
This is proven by placing one of the affected hairs in 
hot water, ether, or turpentine, when the air-bubbles 
will be driven out and the hair will resume its normal 
color. This same infiltration of the hair with air-bub- 
bles will be found also in cases of ordinary canities, 
though usually merely secondary to some interference 
with pigmentation. 

There are various agencies which act as predisposing 
or exciting causes of canities. Age or senility is one 
of the most prominent of these. Heredity exerts a 
marked influence, most of the members of certain 
families turning gray at an early period of life. That 
the nervous system works actively in the production 
of grayness, is shown by the occurrence of sudden 
blanching of the hair under the influence of fear or 
great nervous shock; by the formation of symmetrical 
white bands or tracts of hair during acute outbreaks 
of insanity, which disappear during convalescence, as 
noted by Shaw; and by the hair becoming white in 
parts affected by neuralgia, as of the fifth nerve. 
Hence canities may be regarded as a tropho-neurosis in 
some instances. 

Local diseases or injuries of the scalp, such as 
wounds, repeated epilation, prolonged shaving, have 



W DISEASES OF THE HAIR AND SCALP. 

been known to have local or general canities fol- 
low them. The hair after alopecia areata conies in 
white and may remain so, but usually the white hairs 
fall out to be replaced by normal colored ones. Wal- 
lenberg (119) reports a case of entire loss of hair after 
scarlatina, in which the new hair came in white and 
remained so, the skin at the same time losing its pig- 
ment, and becoming milk white. In this case there 
was a good deal of air in the cortex. The hair has 
been known to turn gray in winter, and to become 
darker in summer. Prolonged residence with much 
exposure, either in a cold or hot chmate, is given as a 
cause of premature grayness. Albinoes, we know, are 
most frequent in the negro races, which inhabit the 
hot countries. Excessive mental application, or pro- 
longed nervous strain, wiU sometimes induce canities, 
which becomes permanent and progressive. In hke 
manner dyspepsia of various forms, excesses of all 
kinds, chronic debilitating diseases such as syphilis, 
malaria and phthisis, profuse and frequent hemor- 
rhages, have been given by various writers as causes of 
canities. In this as in many other diseases, no one 
cause or group of causes can be proven to be the cause, 
but a study of those given will show that they have 
one thing in common, that is a lowering of vitahty. 
The curious phenomenon of "ringed hair" is ascribed 
by Wilson (122) to the development of a gaseous fluid 
"within the hair, and he thinks that either the white, 
opaque and smaUer segments were developed during 
the night, and the larger and normal segments grew 
during the day, or the separate segments were the pro- 
duct of alternate days. The gas may have been gener- 
ated at the time of the formation of the abnormal seg- 
ment, or the cells which composed that segment may 
have been originally filled with an aqueous fluid, which 
evaporated quickly, and was replaced by air penetrat- 



CANITIES, OR GRAYNESS OF THE HAIR. 71- 

ing from without. Landois (109) does xiot agree with 
Wilson, but beheves that we must assume an inter- 
mittent activity of the trophic or vaso-motor nerves of 
the papillae, through whose influence a hair tissue is 
formed, in which a periodic development of gas takes 
place. Lesser (110), in whose case the hair-shaft was 
affected with tricliorrexis nodosa, hkewise found air- 
bubbles in the white or swollen parts, which gained en- 
trance from without through the dry and cracked cuti 
cle of the hair. He offers no explanation for the inter- 
mittency of the rings. In his case there was evidently 
some error in the nutrition of the scalp. Behrend (3) 
regards the disease as a stage of trichorrexis nodosa, 
and says that the process affects already formed hair. 
As yet no answer can be given to the question, '^What 
gives rise to ringed hair ? " 

Treatment. — As a rule nothing can be done to per- 
manently restore the color to white or gray hair. If 
the malady is due to neuralgia, the cure of this will 
sometimes be followed by restoration of color. The 
administration of iron, phosphorus, and sulphur, has 
been advised on theoretical grounds, and may be tried 
if the canities seems to be due to physical debility; but 
no promise of success should be made to the patient. 
The rules of the hygiene of the scalp should be at the 
same time enforced. Plucking the white hairs is worse 
than useless. All that can be done for canities is to 
artificially restore the color by means of hair dyes, and 
their use is to be strongly advised against. Happily 
the custom of dying the hair is falling out of fashion. 

Hair Dyes. — HEBRAand Kaposi (15) give directions 
for dyeing the hair black by "henna, " which is the Per- 
sian name for a small shrub found in the East Indies, 
Persia, the Levant, and along the African coasts of the 
Mediterranean, where it is frequently cultivated. The 
botanical name is Laivsonia Alba; in England it is 



72 DISEASES OF THE TJAVR. ANB SCALP. 

called Egyptian privet, and in the West Indies it is 
known as Jamaica mignonette. In the East it is used 
for dyeing red the nails of women, the beards of men, 
and the manes of horses. The preparation of hernia 
consists in reducing the leaves and young twigs to a 
fine powder, catechu or lucerne leaves in a pulverized 
state being sometimes mixed with them. When re- 
quired for use the powder is made into a pasty mass 
with hot water, and then spread upon the part to be 
dyed. * In an hour the hair wiU be red. A paste of pow- 
dered indigo plant is now applied, and then damp heat, 
and in a few hours the hair will have a fine black color, 
provided that the process has been regxilated by expe- 
rience and good judgment. Leonard (64) gives the 
following formulae for dyeing the hair black: 

No. 1. 

Bismuthi citratis . . § j = 32. 
Aquae rosae 

Aquae destiUat. . . aa 1 ij = 64. 

Alcohohs . . . 3 V = 20. 

Ammoniae . . . q.s. 
M. Sig. Apply in the morning 

No. 2. 

Sodii hyposulphit. . 3 xii = 60. 
Aquae destillat. . . ! iv = 140. 
M. Sig. Apply thoroughly in the evening. 

Nitrate of silver in the strength of from B.Ye to ten 
grains to the ounce of water may be used for a black 
dye, the hair being saturated with it and allowed to 
dry in the sunhght. If it is desired to hasten the pro- 
cess, the application of a solution of sulphuret of pot- 
ash, fi'om twenty grains to two drachms to the ounce 

* Encyc. Brit.^ 9th ed., art. Henna. 



CANITIES, OR GRAYNESS OF THE HAIR. 73 



of distilled water, wiU set the dye instantly. McCall 
Anderson recommends the following for a permanent 
black dye: First, a solution of bichloride of mercury, 
two grains to the ounce of water, followed by a solu- 
tion of hyposulphite of soda, one drachm to the ounce 
of water. Lead may be used in the form of the sugar 
of lead, ten to twenty grains to the ounce of water, 
applied to the hair and followed, when nearly dry, by 
a solution of the sulphide of ammonia, about one- 
quarter the strength of the British Pharmacopoeia. 
These dyes, by means of nitrate of silver and mer- 
cury, are dangerous on account of the metals they con- 
tain. 

For a brown dye, Pfaff (70) recommends a pomade 
composed as follows: 



01. ovorum rec. press. 




Med. OSS. bovis 


.aa 50. 


Ferri lactat. . 


2.50. 


01. cassiae ether. . 


1.50. 


M. 





But the number of dyes is legion, and these must 
suffice for examples. Before the application of any 
dye, the hair should be thoroughly cleansed with soap 
and water. 



CHAPTER V. 

DISCOLORATION OF THE HAIR. 

Synonyms. — Tricolorosi. Trichonosis seu Trichosis 
decolor. 

Under various conditions of health and disease, 
the hair has been known to undergo change in 
color, other than that of turning gray. Some of these 
changes depend upon causes acting from within, and 
modifying in some way the pigment formation. Some 
are due to external agencies, and have the nature of 
dyes. 

Just as serious illness will cause the hair to fall out 
or to turn gray, so will it induce changes in color. 
Some instances of this have been reported. Thus 
Eayer (31) cites two cases of Alibert's, in the first of 
which a young woman after a long and serious illness 
lost a fine head of blonde hair, and upon recovery had 
the loss made good by a growth of very black hair. In 
the second case, a man during sickness lost his brown 
hair, which was replaced after recovery by bright red 
hair. He further cites a curious case in which every 
time the patient, a young woman, was attacked with 
fever, her blonde hair became tawny red, to return to 
its original hue upon recovery. Beigel (123) reports 
a case in which, after typhus fever, the blonde hair of 
a woman fell out, and was replaced by coal black hair. 
Smyly (136) saw the hair of a patient suffering with 
suppurative disease of the left temporal bone, change 
from a mouse color to a reddish yellow. The patient 
was an infant. The left temporal bone was the seat of 
the suppuration, but the right side of the head wa§ 



DISCOLORATION OF THE HAIR. 75 

affected with the change of color of the hair. The 
right eyebrow was hkewise affected. There was also a 
profuse yellow perspiration, so that the pillow and the 
skin of the right side were stained yellow. This case 
was one of dyeing. C. Eeinhard (135) has reported a 
case of periodic change in the color of the hair of an 
idiot boy who suffered with epilepsy and paralysis of 
the legs. He was subject to violent outbursts of tem- 
per, during which his reddish-blonde hair would change 
in forty-eight to sixty hours to a blonde yellow color. 
The change of color seemed to begin at the points of 
the hair, and affected nearly all the hair. After some 
seven or eight days, the original color would return. 
There was no disease of the scalp, excepting that dur- 
ing the stage of quiet, there was a scanty secretion of 
sebaceous matter. Microscopical examination showed 
that the hght hairs contained a good deal of air in the 
cortex and meduUa; that they were dry and inclined 
to spht at their points. Their cuticle cells were dis- 
placed; and the medulla cells were very much shrunken. 
This would be sufficient to explain the change of color, 
as our study of the physiology of the hair has already 
taught us. 

That it may be possible to influence the color of the 
hair by internal medication, is inferred from the re- 
markable case reported by Prentiss (13dt). He had a 
patient with light blonde hair who suffered from pyelo- 
nephritis with anuria, for the relief of which condition 
muriate of pilocarpine was administered hypodermi- 
cally in doses of from 0.01 to 0.02 gramme. The use 
of the drug was begun on December 10, 1880, and the 
hair commenced to grow darker by the twelfth day. 
On the twelfth of January, 1881, the color had become 
chestnut brown, and by the first of Moy it was almost 
pure black, although the pilocarpine was stopped on 
the twenty-second of February. The hair became not 



76 DISEASES OF THE HAIR AND SCALP. 

only darker, but coarser, and grew more vigorously; 
and the hair of the axillae was as much changed as that 
of the head. The hair was in every respect normal, 
and the change in color seemed to depend upon increase 
of pigment. With the change of color in the hair, the 
color of the eye changed from a light to a dark blue. 
This case would tend to show that jaborandi increases 
the nutrition of the hair, and the activity of the pig- 
ment-forming cells. It would appear that the cause 
of the change of color was the jaborandi, because the 
tendency of exhausting diseases, such as pyelo-nephritis, 
is rather towards loss of hair and canities. Jaborandi 
does increase very markedly the cutaneous circulation, 
and to this action we must look for the explanation of 
this case. 

We have no means of explaining with certainty 
these changes of the hair from internal causes. Of 
course they are due to some influence upon the pig- 
ment-forming cells, but that does not explain the mat- 
ter. The cases reported are few, and only in those of 
Prentiss and Smyly does an adequate explanation sug- 
gest itself. The other changes in color of the hair, the 
consideration of which falls within the scope of this 
chapter, are dependent either upon a deposition of 
colored particles from without, or upon chemical action. 
From these causes we have green, blue and yellow hair, 
as well as various anomalous shades. 

Green Hair. — Green hair occurs in workers in cop- 
per. A number of cases have been reported ; the fol- 
lowing one by Petri (132) will serve as an example. 
An old worker in copper, seventy-eight years of age, 
presented the curious appearance of having briUiant 
green hair. He was in good general health. Upon 
his gums was a well-marked green line. Both his beard 
and scalp hair were green. The color did not affect 
\h^ whol^ length of the hair, but was darkest an(J 



DISCOLORATION OF THE HAIR. Y7 

most intense on the point, and for a distance of 3 cm. 
therefrom. From that point it grew gradually less 
pronounced, till at 10 cm. it had disappeared. Be- 
yond this the hair was gray. The microscopical ex- 
amination of the green hairs showed a deposit upon 
the epidermis of the hair, of small, sometimes bluish, 
sometimes indefinitely colored, sometimes darkly con- 
toured or yellowish, sharply cornered, pyramid- shaped 
masses of crystals, with transparent edges. Here and 
there little patches of dirt were found. The crystals 
could be seen only with very strong light. By the ad- 
dition of liquor ammon. caust., the color changed to 
dark or blackish blue, which is the chemical reaction 
of ammonia with the salts of copper. The color could 
be washed out of the hair, and was doubtless due to 
particles of copper oxide floating in the atmosphere of 
the work-shop, and deposited on the hair. Billi (124) 
reports a case of green hair occurring in a patient of 
his, whom he was treating for trichophytosis capitis. 
For the ringworm a wash of corrosive sublimate was 
ordered, and an ointment of the yellow oxide of mer- 
cury. The next time he was seen his hair was a bril- 
Mant green, the color being disseminated over the whole 
head, and the hair colored from bulb to tip. The mi- 
croscope showed that all the elements of the hair were 
colored. The patient was not a worker in copper, nor 
had he used any other application to his scalp. Cases 
of green hair have been reported in which no cause was 
discoverable. Thus Orsi (131) met with a case in a 
railroad hand, who was forty-nine years old, and whose 
hair was gray. Suddenly his hair became green, the 
green hairs being intermixed with the gray and white. 
The scalp hair alone was affected. Washing with vin- 
egar, ether, alcohol or a dilute solution of potash, did 
not affect the color. The microscope showed that the 
roots of the affected hairs were thick and fibrous; tlie 



78 DISEASES OF THE HAIR AND SCALP. 

cortex by natural light was violet, by artificial light 
greenish in color; while the medulla was yellowish. 
When the hair was cut off, gray hair grew in. Even 
in this case, since the hair came in of normal color, 
there was, doubtless, some external agency at work. 
In some cases of canities, a greenish yellow tint will 
be observed, a transition stage from the original color 
to the gray, and this also might be an explanation of 
the foregoing case. 

Blue Hair. — Blue hair is met with in workers in 
cobalt mines and in indigo works. The color is gener- 
ally easily removed by washing, and under the micro- 
scope Beigel (123) found in a case of his own, that the 
whole hair was not uniformly colored, but that particles 
of indigo were deposited in an irregular manner upon 
the cuticle of the hair. In some exceptional specimens 
a number of hairs were embedded for some distance, 
in a mass of indigo, or stuck with neighboring hairs. 
The edge of the epithehal scales were more pronounced 
than in the normal condition, owing to the deposit along 
them of a fine blue dust. The blue color did not pene- 
trate into the substance of the hair. 

Yellow and Black Hair. — Yellow hair has been 
observed in patients suffering from icterus; and black 
or rather coal-black hair is often seen on those who 
work in coal. In aU these cases of change in color of 
the hair from the deposit of foreign matter, the element 
of time was marked, and the lighter the color of the 
hair was originally, the easier did it become altered. 

Change of Color after Death. — The color of the 
hair may change after death. Thus Hauptmann (127) 
reports a case in which the hair of a corpse, exhumed 
after twenty years' biu'ial, was found to have changed 
from a dark brown to a red color. 

Color altered by Chemicals. — The action of vari- 
ous chemical agents will change the color of the hair, 



DISCOLORATION OF THE HAIR. Y9 

the change generally being transitory. This is illus- 
trated by the action of the various dyes and bleaching 
fluids used by the hair -dresser. Further, bicarbonate 
of soda, used for a long time, will change the color of 
dark hair to a dirty red brown. Chrysarobin discolors 
the hair equally with the skin. Chlorine gas will bleach 
the hair. Sweat acts upon the color of the hair, and 
we often find the hair of the axillae of persons who 
sweat much of lighter color than that of the head. 
Leonard (64) cites a case, in which the brown head 
hair of a young man turned to a positive red, after a 
few years' residence in the hot climate of Sumatra. 

Anomalous Cases. — In some cases, according to 
Oesterlen (130), hair will be met with which 
is more intensely pigmented towards its root than 
towards its point, depending upon an irregular 
deposit of pigment, or alteration in the texture of 
the hair. One of the most curious anomalies is re- 
ported by Squire (137) as occurring in a young man 
sixteen years old, the left side of whose head was pie- 
bald like a tortoise-sheU cat. The condition dated from 
birth, and there was no assignable cause. The light- 
colored patches were auburn, the dark patches brown, 
and they were abruptly limited. The opposite or right 
side of the head was covered with dark-brown hair, of 
the same tint as the dark patches on the left side. The 
curious condition known as ringed hair will be found 
in the chapter on Canities in this work. 



CHAPTEE YI. 

ALOPECIA. 

Derivation. — The term is derived from the Greek 
word dXwTrrjC^ meaning a '^fox," on account of its re- 
semblance to the appearance presented in the '' fox- 
mange." 

Synonyms. — Capillorum defluvium; Athrix depihs; 
Phalacrotes; Depilatio; Trichosis athrix; Gangraena 
Alopecia; Atrichia; Defluvium, sen Lapsus seu Fluxus 
Pilorum; Lipsotrichia; Yulpis morbus; Pelada; Ohgo- 
trichia; Calvities; Psilosis; Trichorrhoea; Ophiasis; 
Calvitie, Pelade (Fr.); Kahlheit (Ger.); Calvezza (It.); 
Baldness (Eng.) 

Definition. — An abnormal loss of hair, arising from 
any cause, which usually affects the scalp, but may in- 
vade any portion of the body. 

Varieties. — 1. Alopecia adnata, or congenital bald- 
ness. The form occurring in infants born either totally 
or partially without hair. 2. Alopecia senihs. The 
absolute or relative baldness of old age. 3. Alopecia 
prematura, seu presenihs. Baldness occurring befor 
the time when the hair usually falls, on account of a^ 
varcing years. It may be idiopathic or symptomatic 
4. Alopecia areata, in which the hair falls out in circu- 
lar patches. 

The older writers used various terms to denote 
the different phases of baldness. These, happily, 
have fallen into disuse. They were the following: 
Madesis or Maderosis, used to denote a thinning of the 
hair. Phalacrosis, to denote baldness beginning at 
the forehead. Ophiasis, to signify baldness occiu-ring 



ALOPECIA. 81 

in a serpentine line, running from the occiput towards 
the ears, and sometimes towards the forehead. Opis- 
thophalacrosis, baldness beginning at the back of the 
head. Hemiphalacrosis, baldness affecting one half of 
the head. Anaphalantiasis, used to designate loss of 
the eyebrows, and sometimes general baldness. Oligo- 
trichia, to denote thinness of hair. 

1. Alopecia Adnata. 

Symptoms. — This is the atrichia of the old writers. 
It is congenital baldness, as the name indicates, and is 
either partial or complete. Most infants come into the 
world with a good equipment of hair. In rare instances 
the child is born partially bald, and more rarely com- 
pletely so. Hairless races have been reported. One 
of these is said to exist in Australia. Hill (157). 

Etiology and Pathology. — The disease is due to 
arrested development of the piliary system; and micro- 
scopical examination of sections of the skin in inveter- 
ate cases, shows a deficiency of hair-follicles. In a case 
reported by Jones and Atkins (160), of a boy who 
never remembered having had hair, microscopical ex- 
amination of the scalp revealed only a few aborted 
hair-follicles, forming shallow pits in the epidermic 
layer with open extremities looking downwards. In two 
cases reported by Schede (1Y9) in 1872, one of which 
was a boy thirteen years old, and the other a girl six 
months old, brother and sister, there was no hair what- 
ever on the body, not even lanugo hair. Microscopical 
examination of a section from the boy's scalp showed 
large, well- formed sebaceous glands, opening directly 
on the scalp. In the neighborhood of some of these 
glands, just above their lower extremity, were found 
a great number of '' atheromas " separated from the 
glands by connective tissue, and apparently developed 
in a species of short tubes, which in structure corre- 



82 DISEASES OF THE HAIR AND SCALP. 

sponded with that of the outer root-sheath, and were 
no doubt the beginnings of the rudimentary hairs. 
Luce (166), in 1879, reported a case in which the hair 
did not grow until the sixth year, and in which the 
appearances of keratosis pilaris were present. Hutch- 
inson (158), in 1886, reported a case of congenital ab- 
sence of hair in a boy three and a half years old, the 
son of a woman who had been almost wholly bald from 
alopecia areata since she was six years old. In this 
case there was a withered condition of the whole in- 
tegument, and an absence of nipples. In some fami- 
lies there is an hereditary predisposition to congenital 
alopecia. 

Prognosis. — The prognosis is usually good. The hair 
in most cases wiU grow in course of time, although it 
may not be as abundant as it should be. According to 
MiCHELSON (171), when congenital alopecia takes the 
form of circumscribed patches, the prognosis is bad. 
Delayed dentition and diseased nails wiU often be noted 
in children affected with this disorder. 

Treatment. — As to treatment, the disease usually 
requires none, as it generally remedies itself. If it is 
very disfiguring, or the parents require something to 
be done, stimulating remedies may be used, as in alo- 
pecia areata. If there is keratosis pilaris, the free use 
of soap frictions every day, followed by inunctions with 
oil, will serve to remove the epidermis which clogs up 
the hair-foUicles, and will thus give the hemmed-in 
hair a chance to grow. 

2. Alopecia Senilis. 

Symptoms. — This form of baldness is that which oc- 
curs in old age. It is often preceded, accompanied, or 
soon followed by other signs of advancing years, such 
as graying of the hair, fall or decay of the teeth, and 
diminution in keenness of the sight. The hair usually 



J^^st becomes gray, loses its lustre and suppleness, and 
then falls out either slowly or rapidly. At first there 
may be only a general thinning of the part about to 
become bald, but at last absolute baldness sets in. The 
faU of the hair usually begins at the vertex, and it is 
not uncommon to see this region alone affected for 
some time, giving the appearance of the tonsure. It 
may begin at the anterior superior part of the skull. 
Generally the course of the disorder is from behind for- 
wards, or from before backwards, but the whole top of 
the head may be affected at once. In most cases the 
lateral and posterior parts of the skuU are spared, and 
the bald patch is bounded on either side and behind, by 
a semi-circle of hair, running along the temples to the 
neck. It is always symmetrical. Neumann (27) draws 
attention to the fact that both in senile and premature 
alopecia, the region commonly affected corresponds 
quite nearly to that supplied by both supra-orbifcal 
nerves, and in very extended cases the regions supplied 
by the temporal and the occipitalis major and minor 
are also included. A certain amount of seborrhoea sicca 
is sometimes present. The scalp appears smooth, 
stretched, shiny, sometimes oily, and thinned. 

Etiology. — This form of baldness is but one expres- 
sion of that general lowering of nutrition, incident to 
advancing years. The age of forty-five is that usually 
chosen to designate the dividing hne between man's 
fullest development and commencing decay, and it is 
about this period that senile baldness begins. Women 
are far less often bald than men. Why this is so we 
do not certainly know. In the section on premature 
baldness, some reasons for their exemption wiU be 
given. Neither canities nor seborrhoea are causes of 
this form of alopecia. Kaposi (19) says that atrophy 
of the scalp tissue does not precede, but follows it after 
a considerable lapse of time. 



§4 blBEASES OF THE HAIR AND SCALP. 

Pathology.— There is a lessening of the subcutane- 
ous fat, and an atrophy of the corium, the connective- 
tissue fibres of which have undergone, in part, fatty, 
and in part, colloid degeneration. The sebaceous 
glands are in some places shrunken and in some wid 
ened; the hair-follicles are filled with epithelial scales, 
the remains of the root sheath, and often contain a 
thin hair. In many foUicles the hair-papilla has disap- 
peared. Kaposi (19). Pmcus (71) found in senile 
baldness that there was a rapid relative increase in the 
shedding of the " spitzen " hairs, (that is, those hairs 
which have not been cut), and a marked and increasing 
diminution in the diameter of the long hairs; also an 
absence of seborrhoea sicca in most cases, and a weU- 
marked atrophy of the scalp. Like in other senile 
changes, so here the retrograde process begins in the 
arterial supply to the scalp, and we find a fibrous endar- 
teritis narrowing the lumen of the cutaneous arteries, 
till finally the capillary circidation about the hair- 
follicles is obliterated. 

Prognosis. — The loss of hair is permanent. In some 
rare cases the hair has grown again in old age, and this 
has been attended by the development of new teeth. 

Treatment. — When the scalp is atrophied and bound 
down to the skull, the hair-foUicles are too far gone for 
any stimulation to affect them, and our best endeavors 
to restore the lost hair wiU be in vain. 

3. Alopecia Prematura. 

There are two main varieties of premature baldness; 
Alopecia Prematura Idiopathica, and Alopecia Prema- 
tura Symptomatica. 

Alopecia Prematura Idiopathica 

Symptoms. — Alopecia prematura idiopathica is that 
form of baldness which begins at any time before mid- 



ALOPECIA. 85 

die age, and arises uninfluenced by any antecedent or 
concomitant, local or general disease. Usually the hair 
does not begin to fall before the age of twenty -five 
years, and it is apt to progress slowly. The hairs which 
first fall out, are replaced by those of less vigorous 
growth, and these in their turn are shed to make way 
for still weaker ones, and so the process is repeated 
until complete baldness results. In its general course 
it is similar to the senile form. Like it, it is symmet- 
rical, it begins most often upon the vertex, forming 
the tonsure, it progresses slowly, has the same boun- 
daries which it does not go beyond except in extreme 
cases, and leaves a smooth, shiny, bound-down scalp. 
It often begins anteriorly and recedes at the sides, giv- 
ing that wide and high forehead thought to be indica- 
tive of wisdom. It may leave for a long time a httle 
islet over the middle and anterior part of the skull. 
Unlike senile baldness, it is not preceded by canities, 
or any other senile change. In some cases the fall of 
the hair will be rapid, then cease for a time, to begin 
again and progress steadily. The beard in all forms of 
baldness is affected rarely, a luxuriant beard being 
very often associated with a more or less bald head. 

Etiology. — The disease is in many cases hereditary, 
it being not uncommon to meet with families in which 
the fathers and sons for many generations lose their 
hair early in life. PiNCUS (173) says this is due to a 
markedly stretched condition of the aponeurosis of the 
occipito-frontalis muscle, which becomes hereditary in 
certain families. According to him, 'Hhere are but 
two predisposing causes of alopecia prematura. They 
are: 1. Inheritance. 2. A chronic eczema or impeti- 
ginous eruption on the scalp, in the years preceding- 
puberty. The latter is the most frequent, and is often 
connected with symptoms of relative or absolute debil- 
ity." It is very prevalent in those leading sedentary 



^6 DISEASES OP THE HAIR AND SCALP. 

lives, especially so in brain-workers. The continuous 
wearing of caps or of close-fitting unventilated hats, a 
practice very common in this country, is assigned as a 
cause. Some hatters claim that according as the head 
is long or wide, the baldness commences on the fore- 
head or crown. F. A. King (161) says '' baldness of 
the vertex is due to compression by stiff hats, of the 
anterior temporal arteries in their course over the fron- 
tal protuberances; of the posterior temporals at or near 
the ]3arietal ridges; and of the occipital behind. The 
reason why baldness occurs in different places in dif- 
ferent individuals is probably due to differences in the 
shape of the head. The httle tuft of hair often ob- 
served on top of the forehead, is nourished by the two 
supra-orbital arteries, which escape pressure, by pass- 
ing over the forehead in the sUght concavities between 
the frontal eminences." The existence of the islet of 
hair in front is probably dependent upon the fact that 
it hes over the frontalis muscle, and is not upon so 
tense a substratum as the other hair of the vertex. 
Lack of care of the hair is an active cause. Ellinger 
(150) believes that the daily use of water on the head 
is a frequent etiological factor, and has found this the 
case in eighty-five per cent, of his cases. He says '' the 
form due to water begins at the forehead, and precedes 
upward and to the sides; it occurs in people who wear 
the hair long, and is due to the fact that the water at 
the point of exit of the hair, makes an emulsion with 
the sebum, and the scales of epidermis, which, harden- 
ing, forms a plug to the hair-foUicle, causes a damming 
up of the sebum in the follicle, and subsequent atrophy 
of the hair. " In a recent article upon alopecia by Pohl 
PiNCUS (177) it is held that all forms of the disease are 
due either to primary or secondary induration of the 
scalp. Some causes of primary induration are said by 
him to be the action of cold, as by an ice-bag, gleet, 



ALOPECIA. S? 

leucorrhoea, great depression of spirits, or anxiety of 
mind, which the subject struggles against; while in 
those cases in which the subject succumbs entirely to 
his depression, these do not cause baldness. 

It has been noted that eunuchs generally have hair 
neither on the face nor pubes, if they are castrated be- 
fore puberty; and if castrated after puberty, they lose 
whatever hair they had on those regions. Women less 
often become bald than men. The reasons given for 
this exemption, are that they do not wear their hats as 
much as men, neither are their hats so close fitting, 
nor made of so impermeable materials as are men's 
hats; that they give more attention to the care of their 
hair than men do; that they carefully avoid wetting 
their hair; that they are not so abundantly covered 
with hair as are men, and therefore do not suffer so 
great a drain upon the hair-forming elements; that the 
hair is not so often cut; and that there is a greater 
amount of subcutaneous fat in women than in men, 
and this is preserved longer in them. Pincus says 
*'the reason why they suffer less, is due to the fact 
that in them the spaces between the connective-tissue 
fibres, in the deeper and middle layers of the scalp, are 
much larger than in men, the skin of women during 
their life preserving more of the characteristics of the 
skin of children. 

That the beard is not affected is because the 
underlying tissues are not so stretched, as is the case 
with the part of the scalp most often affected, that 
is, the region over the occipito-frontalis aponeurosis. 
This reason would also hold good in regard to the 
exemption from baldness of the other hairy regions 
of the body, and of the parts of the scalp hair which 
usually do not fall out. 

Pathology.— From birth up to the age of twenty 
years the scalp undergoes a continual change in struc- 



88 DISEASES OF THE HAIR AND SCALP. 

ture, which consists in increasing thickening and ten- 
sion of the middle layer of the connective tissue, this 
being most marked in the regions most commonly af- 
fected by alopecia, namely, over the aponeurosis of the 
occipito-frontalis muscle, and least marked on the 
temples. In both alopecia prematura simplex and alo- 
pecia senilis the connective-tissue which binds the scalp 
to the underlying parts, suffers still further changes. 
It undergoes a narrowing of its meshes with a thick- 
ening of its fibres, tiU at last in many places the meshes 
disappear. At first the hair loses its typical length, 
but not thickness, its lustre is somewhat diminished, 
and both the quantity and quahty of daily fall is slightly 
increased, more short hairs being shed in proportion to 
long hairs than normally. At the same time sebor- 
rhoea sicca generally becomes iDronounced, though in 
about ten per ceat. of the cases it is wanting. The 
thickening of the subcutaneous tissue progresses slow- 
ly, but at last in from six months to five years, the 
hair begins to lose in thickness, and to fall more rap- 
idly, and baldness sets in. The diameter of the hair is 
in direct proportion to the diameter of the papiUa; and 
as the papilla is more and more pressed upon and re- 
duced in size by the increase of the connective-tissue, 
the diameter of the hair is steadily lessened. At first 
the papillae are unaltered in constituence, later they are 
obhterated, and then no more hair can be produced, 
and the part is bald. If the process of induration 
greatly increases, it goes beyond the aponeurosis, and 
the whole head becomes quite bald. Pincus (173). 

Prognosis. — If the disease has not progressed too 
far, we may sometimes stay its progress. If the scalp 
is so tightly adherent to the subcutaneous tissues that 
it does not readily shde upon them, we can not hope 
to better the condition. A weU-marked history of 
heredity renders the prognosis unfavorable. We can 



ALOPECIA. 89 

best watch the progress of the case by having the pa- 
tient save all the hair that falls from his head for three 
days, putting each day's fall by itself, and then count- 
ing the pointed and cut hairs, if the case occur in a man, 
or the hairs over and under six inches, if the case occur 
in a woman. If the uncut hairs of a man, or the hairs 
under six inches of a woman, exceed one quarter of 
the mass, the disease is progressive, and the prognosis 
is unfavorable; if under one quarter the prognosis is 
better. 

Treatment. — In persons who have reason to expect 
early hereditary baldness, prophylaxis is of the great- 
est importance. This consists in close attention to the 
hygiene of the scalp, and of the general health. "When 
the disease has once set in, it must be combated by 
means of stimulating applications, as in symptomatic 
premature baldness. Shoemaker (182 and 183) recom- 
mends that to persons in apparent good health, who 
are unconsciously losing their hair, either mercury, 
tincture of ignatia, or sulphurous acid should be ad- 
ministered. Either the bichloride of mercury or calo- 
mel is given by him for a short period, and then the 
tincture of ignatia in ten-drop doses three times a day 
with a bitter tonic, and thus the treatment is varied 
from time to time, according to the patient's condition. 
He also advises the use of the oleate of iron locally in 
these cases. The use of jaborandi or pilocarpine would 
seem to hold out some hope for the cure of this affec- 
tion. In 1879 two remarkable cases of hair growing 
on perfectly bald heads were reported by Geo. Schmitz 
(180), after using two or three hypodermics of pilocar- 
pine for some eye diseases. In one case the man was 
sixty years old and quite bald, and yet a vigorous 
growth of gray and black hair took place and covered 
his scalp. In the other case the man was thirty-four 
years old, with a small bald spot upon which the hair 



90 DISEASES OF THE HAIR AND SCALP. 

grew so as to cover it. Cottle (52) speaks highly of 
the power of either of the following lotions to stop the 
fall of the hair, namely: 

Ac. Acetici . . . gss. = 15 

Pulv. boracis . . 3j. =4 

Glycerine . . . 3iij. = 12 

Spts. villi . . . 1 ss. = 15 

Aq. rosae ad . . . |viij.= 24:0 

M or 

Liq. ammon. acetat . § ij. = 60 

Amnion, carbonat . 3 ss. = 2 

Glycerine . . . 3 iij. = 12 

Aq. sambuci . . ad iviij.=:21:0 
M 

PiNCUS (175) advises in acute idiopathic loss of hair 
the avoidance of all stimulation of the scalp, and tem- 
perance in eating, drinking and mental excitement. 
Where the fall of the hair is progressive and chronic, 
and while it is still merely a thinning of the hair, he 
directs the application to the scalp, for two to five 
minutes on two or fom- successive days of each week, 
of a lotion composed of: 

Bicarbonate of soda . . 4 

DistiUed water ... 180 

M 

rubbing in one to two tablespoonfuls with a soft hair- 
brush or a sponge. On the first or second day of the 
interval between the apphcations, some oil is to be 
rubbed into the scalp. This treatment is to be con- 
tinued for a year, and then if the disease stiU pro- 
gresses, more powerful remedies are to be used, such 
as will be spoken of under the treatment of alopecia 
furfuracea. 



alopecia. 91 

Alopecia Prematura Symptomatica. 

Symptoms. — As its name indicates this form of bald- 
ness occurs as a consequence of some other local or 
general disease. It may occur at any time before old 
age and be either circumscribed or diffused, depending 
upon its cause. It may be very rapid, as after fevers, 
the hair falling out by handfuls, in which case it is 
named ''defluvium capillorum; " or it may be very 
slow, as in seborrhoea sicca, taking years to produce 
complete baldness. Other parts of the piliary system 
may suffer besides the scalp hair, as in trichophytosis, 
spyhilis, etc. In some cases all the hair of the body 
has fallen out at once, as after sudden nervous shock. 
When dependent upon non-symmetrical diseases, as 
variola, pustular diseases in general, and the parasitic 
diseases, the baldness will be asymmetrical. 

Its main varieties are : alopecia f urf uracea or alopecia 
pityrodes; alopecia syphilitica; defluvium capillorum; 
and a class comprising the non-symmetrical cases aris- 
ing from local lesions, which has been named by 
T. EoBiNSON (75) "alopecia f ollicularis. " The most 
frequent cause of alopecia prematura symptomatica, is 
seborrhoea sicca or pityriasis simplex, and on this ac- 
count oar first attention must be given to 

Alopecia Furfur acea. — In this there is always 
some scaling of the scalp, it may be in so slight a 
degree as to constitute the commonly called "dan- 
druff," or pityriasis simplex; or the process may be so 
intense as to produce the thick, easily friable, grayish - 
white, greasy scales of seborrhoea sicca. This 
kind of baldness is met with in all ages, but its most 
serious form occurs usually between the twentieth 
and thirtieth year of life. It has two stages. In the 
first stage, simple seborrhoea sicca or pityriasis is pres- 
ent, and the hair is dry and falls out slightly. The 



92 DISEASES OF THE HAIR AND SCALP. 

subject notices that his clothing, especially about the 
shoulders, is covered more or less thickly with grayish 
epithehal scales mingled with sebaceous matter, and 
that these fill his brush; and that a few hairs fall out 
of themselves or are pulled out by combing. This 
stage lasts from two to seven years, as a rule. Now 
the second stage begins, when to the seborrhoea is 
added a rapid fall of the hair. The location usually 
affected is the same as in alopecia senilis, the top of the 
head, from vertex to forehead, and sometimes over the 
temples, and the tuft of hair just over the forehead is 
preserved longest. The patient does not become bald 
at once, as there is at first only a thinning of the hair; 
then a diminution in the length and diameter of the 
hair; but the atrophy continues till at last only a few 
lanugo hairs are left, which in their turn fall out and 
complete baldness results. The bald scalp appears 
white or of rosy hue; is often stretched over the 
sutures, though frequently easily moved over the 
aponeurosis of the occipito-frontalis muscle; and it 
seems thinned. The seborrhoea keeps pace with the 
intensity of the disease, until the hair falls out markedly, 
when it lessens, and when baldness is fully estabhshed 
it is no longer present. 

Such is the usual course of the disease. In infants 
seborrhoea generally gives rise to thick crusts, which, 
being removed, bring away with them the first growth 
of the hair. In them it does- not produce permanent 
baldness. In women the region affected is generally 
that occupied by the part. It is affirmed that they are 
more prone to seborrhoea sicca and f aU of the hair than 
men are, but that the process in them is only passing, 
and the faUen hairs are soon replaced. Seborrhoea sicca 
will also produce a general thinning of all the hairy 
scalp, but this is usually an acute and temporary 
trouble. 



ALOPECIA. 93 

PiNCUS (71) says: ''In alopecia pityrodes the definite 
proportion between the hair growth and fall is dis- 
turbed, the latter becoming excessive. The longer the 
seborrhoea lasts the more the hair growth will fall 
behind. When the proportion of short hairs to the 
total fall is as 1:8, the average length of the hair being 
five inches; or as 1:10, the average length of the hairs 
being from two to three inches, the loss is abnormal. ' ' 
If under treatment the disease is checked, and the 
process has not lasted long enough to cause destruction 
of the hair bulbs, improvement will be shown by a 
lessening of the fall of the hair, and by and by a growth 
of lanugo hairs and then of good strong colored hairs. 

By Unna (186) a method is proposed for proving the 
improvement, which is as foUows: The patient is di- 
rected to gather the fallen hairs into a little bundle 
with the roots aU looking one way, so that the condi- 
tion and number of them can be seen at a glance. So 
long as the fall is rapid, many hairs will be found which 
have just passed the papilla stage, whose knob-like 
roots are stiU long, and often have a^rawn-out epithe- 
lial projection. The less the fall is the less this form of 
root wiU be found, till only the rounded fuU roots are 
met with, which shows that the hairs have been a long 
time in the '' beet-haar " stage.* 

Alopecia Syphilitica next claims our attention. 
It occurs most often early in the disease with the early 
specific lesions, but may occur later, with the tubercu- 
lar and gummatous lesions. Syphilitic exanthems may 
be present on the scalp, or the alpoceia may be the only 
symptom of the disease. It has no definite time of 
appearing, coming as early as the third month, or as 

*By " beet-haar " is meant a hair which has been cast off from 
its papilla, but not shed from the follicle. It is one of the regular 
stages in the lifr^ of every hair, and shows that it hcis attained it§ 
full <Jev^lopiu^ut'- 



94 DISEASES OF THE HAIR AND SCALP. 

late as the end of the second year. When it is the result 
of the syphilitic cachexia, seborrhoea is often present, 
and there is a general thinning of the hair all over the 
head, with the formation of irregular patches of bald- 
ness which do not tend to form circles. In the patches 
we often find tufts of long hair, and the head has a 
peculiar ragged look which is quite characteristic. In 
some cases the middle region of the scalp is alone 
affected. When it is due to a pustular or ulcerating 
lesion the baldness is locahzed at the seat of the lesion, 
and cicatricial tissue not infrequently takes the place 
of the normal scalp tissue. 

Other regions besides the scalp may be affected, but 
always at the same time with the scalp. The broken 
arch of the eyebrows is characteristic. Alopecia of the 
eyelashes is less frequent. The hair of the pubes is 
quite frequently attacked, specially, according to Four- 
nier (152), is this the case in women. 

Usually there are no subjective symptoms, and the 
fall is more rapid than in other forms of alopecia. It 
comes in both benign and malignant cases, more often 
in the latter. Some authorities say that it is not so 
common as it used to be ia former times when it was 
the custom to salivate the patients, and hence it is in- 
ferred that it is due to the administration of mercury. 
While we know that alopecia is one manifestation of 
chronic mercurial poisoning, yet as alopecia occurs in 
syphilitic cases in which no mercury has been used, we 
can feel assured that syphilis of itself is a sufficient 
cause of the baldness. 

Defluvium Capillorum is the form of baldness 
which f oUows acute diseases, especially fevers, or oc- 
curs in the course of some cachexia such as mercuri- 
alism. Usually the hair does not fall out till after con- 
valescence has set in, when the faU wiU be very rapid. 
It is more apt to be a general thinning, attacldng all 



ALOPECIA. 95 

parts of the scalp, than a locahzed baldness, and in most 
cases is associated with seborrhoea. As a rule it is 
not very intense, and rarely produces absolute baldness. 
At times, however, the hair of the whole body will fall 
with great rapidity so that the disease will have a 
strong resemblance to alopecia areata maligna. 

Alopecia Follicularis. — The appearance presented 
by this form will vary with the cause. When due to 
pustular diseases, as impetigo, the patches are not larger 
than from the size of a dollar to that of the palm and 
we may have cicatrices. When due to some diffuse 
inflammatory disease as erysipelas, the patches are quite 
large and irregular, and the scalp is hyperaemic. When 
due to favus or ringworm the hairs are altered; in the 
former case they are lustreless, dry, brittle and some- 
times split longitudinally; in the latter they appear as 
if gnawed off near the roots. The scalp, too, is altered; 
in favus in old cases it is more or less atrophied; in 
ringworm it is usually covered with thick scales form- 
ing a crust. 

Etiology. — Alopecia prematura symptomatica has 
many causes. We have already mentioned seborrhoea 
sicca, syphilis, fevers, impetigo, erysipelas, variola, 
and parasitic diseases. Besides these may be mentioned, 
violent shocks to the nervous system and mental dis- 
tress; parturition, lupus erythematosus, psoriasis, lichen 
ruber, hchen seroj)hulosorum, lepra, and other cachex- 
ise. 

The baldness following fevers, and with syphilitic 
and other cachexiae, is due in most cases to seborrhoea, 
but may be purely a nutritive trouble, the bulbs being 
badly nourished, the hair becoming loose and falling- 
out. This view is supported by the fact that the hair 
does not fall out till some time has passed since the 
onset of the fever, and grows in again when convalos- 
(jcuce is fully established. The balclness of the pustular 



96 DISEASES OF THE HAIR AND SCALP. 

diseases, such as variola and the syphihdes, and of the 
destructive diseases, such as lupus erythematosus, is 
due to the destruction of the hair-follicles. The bald- 
ness which is found to follow the use of mercury, ex- 
cesses in venery and intemperance, is due to their dam- 
aging effect upon the constitution of the patient. 
Anything, in fact, which will tend to impair the full 
vigor of a man, may secondarily contribute to the pro- 
duction of baldness, especially if he has a predisposition 
thereto. This it may do by its effect upon the nutri- 
tion of the hair, or more commonly through a pityriasis 
simplex or seborrhoea sicca. 

Lassar and Bishop (163) maintain that alopecia fur- 
furacea is contagious, and is frequently transmitted by 
the agency of barber's brushes and combs. Hence, 
they state, women are less often affected than men, 
because they are not so much exposed to infection at 
the hands of the barber. They base their opinion upon 
the following experiments: They took a twenty-five 
years old student, of sound health and without nervous 
tendency, belonging to a family in which baldness was 
uncommon. This student had been growing bald for 
five or six years. The baldness was absolute only over 
the forehead, but the hair was very thin from there to 
the vertex, the sides being spared. In the thin part, the 
hair was short and dry. The hair of the neighboring 
parts was somewhat lustreless and brittle, coming out 
easily on sHght traction. There was only a slight, 
dusty pityriasis. There was a httle itching, and the 
scalp showed some excoriated places made by the 
patient's nails in scratching. The itching had been 
present for some years, especially when he was work- 
ing or reading. The hair loss had been gradual till the 
preceding summer, when during a foot tour in hot 
weather, it had increased more rapidly. From this 
student'? shed hair andl scales, a poma(ie was made uy 



ALOPECIA. 07 

chopping them up fine and mixing them with vasehne. 
This pomade was spread over the back of a guinea pig 
and of a rabbit, and the animals watched while kept 
in the best hygienic surroundings. In the course of 
three weeks there formed upon the backs of these ani- 
mals patches of absolute baldness as large as the palm 
of the hand; other places showed marked thinning of 
the hair, which came out with the slightest traction; 
and there was present a mealy desquamation similar to 
that on the student's head. To control this experiment, 
it was repeated on another guinea pig and rabbit, and 
upon yet a third rabbit; in these cases the hair being 
taken from No. 1 and No. 2 respectively. The results 
were in all cases similar, only attained more rapidly. 
In aU the cases the baldness preceded from the infected 
into the sound parts. 

In 1874, Malassez (169) and Chincholle (142) de- 
scribed a vegetable parasite as present in pityriasis sim- 
plex, oval in shape, which disappeared with the disap- 
pearance of the ptyriasis. Malassez described it as 
"constituted of spores without tubes of mycelium, 
generally oval in shape, seldom spherical, and very 
small. It inhabits the corneous layer of the skin, and 
penetrates the follicles, but does not reach the orifice 
of the sebaceous gland. It is generally very abundant, 
and is the cause of the disease." Eecent investiga- 
tions by BizzozERO tend to show that these spores are 
found generally upon the normal human skin. (603.) 

Much that has been given in the etiology of idiopa- 
thic alopecia prematura, especially in regard to the use 
of water on the head, the wearing of hats, etc., could 
be repeated here, since they tend to produce pityriasis 
and in that way alopecia furfuracea. 

Pathology. — As we have learned, the majority of 
the cases of premature symptomatic baldness that are 
not due to destructive diseases are due to seborrhoea or 



08 DISEASES OF THE HAIR AND SCALP. 

pityriasis simplex. We will, therefore, give our atten- 
tion first to the pathology of alopecia furfuracea seu 
pityrodes. In seborrhoea sicca there is a too hasty cast- 
ing off of the Hning cells of the sebaceous glands, and 
as these are continuous with those Hning the hair-folli- 
cle, it is probable that a hke increase in the shedding of 
the cells of the hair-foUicle takes place. This must be 
followed by interference with the nutrition, and loosen- 
ing and falling of the hair. If the process can be 
stopped before the papillae become atrophied the hair 
will grow again. If the process has continued un- 
checked for from six to ten years, the papiUae will 
probably be destroyed, and the baldness wiU. be perma- 
nent. The normal life of a hair is one year or more; it 
may be three months or less. The shorter time the hair 
lives, the shorter and thinner it will be. In this form 
of alopecia, the quantitative proportion of the short 
(''spitzen") hairs to the total shed hairs is increased 
markedly without the absolute daily hair loss being 
as markedly increased. The characteristic of the first 
stage is that hairs suffer an increasing diminution in 
their normal length, the later growths often having a 
markedly shorter length of life than those that have 
gone before. The lessening of the length of growth 
is due to a shortening of the typical life. The charac- 
teristic of the second stage is a reduction in the diame- 
ter of the hair. The hairs occur in bundles of from 
three to five together. The life, length, and diameter 
of the hairs in the same group vary considerably, and 
they do not aU die at the same time. In fever pro- 
cesses, however, a whole group often faUs at once. 
Pmcus, (173), 

Malassez (170), a supporter of the parasitic theory of 
alopecia pityrodes, explains its occurrence as follows: 
The parasite causes an irritation of the foUicular waUs, 
foUowed by their hypertrophy. This hypertrophy 



* 



ALOl^EClA. 09 

closes the cavity of the foUicle, causes a fibrous trans- 
formation of the foUicle, and final fall of the hair. 

In defluvium capillorum, when it does not depend 
upon a pityriasis or a seborrhoea, we may find an ex- 
planation for the sudden fall of the hair in the ar- 
rangement of the blood supply as suggested by Unna, 
(82 a) and given on page 38 of this book. 

Prognosis. — This will vary with the cause. The 
prognosis of alopecia furfuracea is good if proper 
treatment is begun while the hair is only thinned, and 
the scalp is not actually bald. Then we have fair 
ground for hope if there is no predisposition to the 
disease and lanugo hairs are present. When the scalp 
is atrophied and bound down to the skull, the prospects 
are bad. Pmcus says that the nearer to puberty the 
disease begins, the more rapid will be its course. 

The prognosis of defluvium capillorum is usually 
good. This is especially the case after fevers and par- 
turition. It may be generally stated that the prog- 
nosis of alopecia, due to local disease of the scalp, is the 
more favorable the more superficial the disease is which 
causes it; thus, it is good after eczema and erysipelas, 
bad after lupus and the ulcerative diseases, in which 
there is destruction of tissue and production of cica- 
trices. 

Before beginning the treatment of any case we must 
explain to the patient that rapid results cannot be 
expected, and success will depend largely upon the 
care with which he carries out directions, and upon 
his perseverance. At least one year of treatment must 
be stipulated for. I have found that women will give 
much more attention to the physician's directions than 
men, and this is probably one reason why results are 
more satisfactory with them. 

Diagnosis. — Alopecia prematura symptomatica is 
diagnosed from the other forms of alopecia by, usually, 



100 MsHASeS of The hair ANI> f^iCALP. 

the presence of a seborrhoea or some local disease, by 
its mnning a more irregular course, and by a less 
marked atrophy of the scalp. From senile alopecia 
the absence of other senile changes will distinguish it; 
and the lack of smooth, circular, oval, or serpiginous 
patches serves to differentiate it from alopecia areata. 

Alopecia syphilitica is diagnosed by its sudden inva- 
sion; by its non -inflammatory and non-pruritic char- 
acter; by the ragged appearance it gives to the hair 
with its irregular patches of baldness; sometimes by 
the presence of syphihdes on the scalp or elsewhere on 
the body; and by the history of infection. 

Treatment. — Prophylaxis. — It should be especially 
urged upon those predisposed to baldness that, by 
proper care of the hair and scalp, much may be done 
to prevent the early fall of the hair. The prophylactic 
treatment consists in brushing and combing the hair, 
washing the scalp, the avoidance of the abuse of local 
appHcations, and the attention to certain hygienic 
laws; matters which have already been fully consid- 
ered in the chapter on hygiene. 

Curative Treatment. — When due to seborrhoea or 
pityriasis, the first thing to be done is to remove all 
crusts and scales. This is accomplished by the use of 
soap and water when there is only scaUness, and for 
our soap, the tincture of green soap, composed of equal 
parts of sapo viridis and alcohol or cologne water. Is 
the best. This acts both as a cleanser and a stimulant. 
The soap should always be washed out with a copious 
stream of water, using it hot and cold alternately, 
when convenient. If there is a tendency to dryness 
of the hair, as there generally is in these cases, after 
drying the scalp and hair carefully, rub into the scalp 
a little oil or vaseline. Or instead of the soap, if tlie 
scalp is very irritable, we may use a shampoo of eggs — 
the yolks of three eggs beinT beaten up in one pint of 



ALOPECIA. 101 

lime water, to which half an ounce of cologne water 
may be added. Rub this thoroughly into the head after 
carefully brushing it, and wash out the same as after 
using soap. Where there are thick crusts this will 
not suffice, and we must use oil. L3t the patient 
saturate the head with sweet almond oil, put on an 
oiled silk cap, and keep it on all night. The next 
morning wash the head with borax an J water. This 
is to be repeated every night until the head is clean, 
and afterwards an occasional wash with the tincture 
of green soap or borax and water will suffice for clean- 
liness. 

Cases of alopecia furfuracea as a rule need stimula- 
tion, and to this end a multitude of hair tonics have 
been used, such as carbolic acid; tincture of cantharides; 
tincture of cinchona; tincture of nux vomica; tincture of 
capsicum; ammonia; chloral; corrosive sublimate; and 
the like. The good these substances do is by their 
stimulating properties, and no one of them can boast of 
any specific action. They must be made strong enough 
to cause the scalp to glow, but not to irritate it to the 
point of inflammation. 

CarboHc acid may be used as strong as two per 
cent, in alcohol: tincture of capsicum, and tincture of 
cantharides of the strength of 3 j — iij (tt.O to 12.0) to 1 j 
(30.0); chloral, up to 3 j (4.0) to 1 j (30.0); tincture of nux 
vomica say 3j (4.0) to Ij (30.0); corrosive sublimate 
gr. i — iij to I j ; aq. amnion, fort, may be used in some 
cases pure, but better, diluted to the point of tolera- 
tion. 

Or ointments containing these or other substances 
may be used. A good one is 

Hydrarg. amnion., . . gr. Ix. — 3 
Hydrarg. chlor. niitis, . gr. Ixxx. — 6 
Petrolati, . . .ad 53. — 32 

M. 



10^ DISEASES OF THE HAlU AND SCALP. 

Sulphur also acts well, in the strength of 3 ss — ij, 
to ? j. Unna (186) recommends: 

Sulph. precip, 3. 

Adeps, 30. 

M. 
rubbed in every evening, at first from before backward, 
and then around and around. Every three or four days 
the head is to be washed. So soon as desquamation 
lessens, rub in every second evening, and so gradually 
decrease. If the scalp is irritated, he substitutes ungt. 
zinci oxid. for the lard in the above prescription. Sul- 
phur has proved itself of value in my hands. 

PiNCUS (175) advises in the first stage, when the scal- 
ing is pronounced and the hair begins to fall, a solution 
of bicarbonate of soda strong enough to redden the 
patient's forehead after rubbing it a few minutes. This 
is to be rubbed thoroughly into the scalp, a compress 
to be apphed over it, and an oil silk cap to be worn all 
night. One objection to this is that it stains the hair 
a dirty reddish brown. In the second stage, when the 
hair faU is pronounced, 1^ Tanin gr.lxxx (6.00); ungt. 
rosae 1 j (30.0) is to be rubbed in every night, and the 
head cleansed two or three times a week. A lotion of 
01. sabinse gr.v—xxx(0. 30—2.0) to alcohol ? j (30.0) M. 
apphed every night is better, as it may be interrupted 
for two or three weeks at a time, while the tannin cannot 
be stopped more than six days. A hood is to be worn 
during the night with either of these. The ol. sabinse 
often causes headache, nausea, vertigo, and sleepless- 
ness, which is an objection to its use. 

PoHL PiNCUs (177) advises the use of a lotion compos- 
ed as follows: 

Ac. lactic, . . . . 0.5 to 1.0 
Ac. boracic, . . . 2.0 to 5.0 

Aq. destilat, . . . 220. 

Spts.vini rect. . . . 30 to 40. 
M. 



ALOPECIA. 103 

Two to three teaspoonfuls of this are to be rubbed into 
the head once or twice daily for three or four minutes. 
Or an ointment may be substituted composed as fol- 
lows: 

Ac. lactic, . . . . 0.25 to 0.75 
Ac. boracic, . . . 2.0 to 3.00 
Adeps, vel 

Vasehne, 25.00 

01. bergamii, .... q.s. 

M. 
Two to four pea-sized masses of this are to be rubbed 
into the bald places once or twice daily for three min- 
utes. After using either of these for two or three 
weeks, he makes a pause of a few days, and then for 
one week uses: 

Sodii carbonat, . . . 0.75 to 2.0 
Adeps, vel 

Petrolati, 25.0 

01 bergamii, . . . . q.s. 

M. 
in the same manner as the previous ointment, and so 
alternates his remedies for a year. 

Lassar (163) managed the case cited under etiology 
upon the antiparasitic plan, with the result of causing 
a growth of strong new hair by the end of the eighth 
week. The patient's head was daily washed with a 
strong tar soap which gave a good lather, which was 
rubbed in for fifteen minutes. The soap was then 
washed out with water, at first warm, then gradually 
cooler, at last cold. Then a wash composed of equal 
parts of a solution of corrosive subhmate (1. to 300.0), 
spts. cologne and glycerine, was thoroughly applied. 
The head was then dried and a napthol solution (nap- 
thol. 0.5; spts. dilut. 70.0; aq. destil. 30.0) was rubbed 
in. Finally a one and a half per cent, solution of 
carbohzed oil was slowly poured over the head. 



esorcin as follows: 
5 
45 
. 150 
0.6 



104 DISEASES OI' THE HAlR AND SCALP. 

Heitzmann (156) has quite recentlj recommended in 
these cases the use of crude oleum, rusci in the propor- 
tion of 10 per cent, to 20 per cent, in an ointment of 
vaseHne and paraffin, with enough fragrant oil to cover 
the smell of the tar. This is to be alternated with 
sulphur and white precipitate ointments. He claims 
that twenty-four per cent, of two hundred cases were 
temporarily benefitted, and in a small percentage the 
improvement was lasting. 

Ihle (159) recommends the use of 

Eesorcin pm*, 

01. ricini, 

Spts. vini. 

Bals. peruv. 
M. 
This is to be rubbed into the scalp daily with a piece of 
flannel. It forms an agreeable mixture with a slight 
odor of alcohol. This drug, as well as icthyol, has also 
been highly recommended by Unna. 

So much for local measures. As seborrhoea is an 
indication of lowered vitality, the general health must 
be cared for, and tonics given when indicated. 

In syphilitic alopecia our main dependence is upon 
the internal treatment — mercury or iodide of potassium 
being used according to the stage of the disease. Lo- 
cally, if any lesions are present, we may use a lotion of 
bichloride of mercury, or an ointment of the ammoni- 
ate of mercury. Stimulating remedies, as in alopecia 
furfuracea, may be used with advantage. Defluvium 
capillorum takes care of itself in most cases. Its 
treatment, when needed, is that of alopecia furfuracea. 
Alopecia arising froyn local diseases needs the treat- 
ment applicable to the special disease present, which 
will be given in the appropriate chapters of this work. 
In pustular diseases affecting the scalp, if the hairs are 
early extracted before the f oUicles are destroyed, much 
will be accomphshed to prevent alopecia. 



CHAPTER TIL 

ALOPECIA AREATA. 

Synonyms: — Area Celsi, (v. Barenspriing); Area oc- 
cid entails diffluens, serpens, sen tyrla; Alopecia cir- 
cumscripta, (Fuchs); Alopecia occldentalls, (Wilson); 
Porrigo sen tinea decalvans, (Bateman) ; Vitiligo capitis, 
(Cazenave); Ophiasis; Pliytoalopecla, (Gruby); Teigne 



Alopecia Areata. 

pelade, (Bazln); Pelade acromatosa; Pelade decalvante, 
or, ofiaslca; Pelade (Fr.); Die Krelsfleckige Kahlhelt, 
(Ger.); Circumscribed baldness, (Eng.). 

Definition. — A disease of the hair characterized by 
its sudden fall and the production of perfectly bald, 
smooth, usually circumscribed and circular patches, 
which generally affects the scalp, but may invade 
pther hairy parts; runs a chronic course without con- 



106 DISEASES OF THE HAIR AND SCALP. 

comitant symptoms, and tends towards spontaneous 
recovery. 

Symptoms. — The disease usually begins suddenly, 
the patient finding to his surprise a bald circular spot 
upon the head without knowing when it formed. In 
a number of cases there will be a history of severe, 
often periodic, and localized headache preceding the 
hair-faU for weeks or months. In other cases some 
shght pruritus, burning, or pain may ante-date the 
alopecia. In any event the patch forms suddenly, the 
hair falling out at once. The size of the patch varies; 
it may be very smaU or it may be as large as the palm 
of the hand. When it exceeds the latter size, it is 
usually formed by the coalescence of smaller patches. 
It tends to gain its full size at once and to remain 
circumscribed, but in some cases it pushes out into the 
surrounding parts, either preserving its circular shape, 
or becoming irregular or serpiginous. There may be 
only one patch but more commonly there are two or 
three patches, which appear simultaneously or succes- 
sively. The disease most frequently affects the scalp 
and may be symmetrical. Its next most common seat 
is the beard. It may, however, affect aU the hairy 
parts of the body, and in some cases cause universal 
baldness. 

The appearance of the disease is striking, and not 
readily forgotten when once seen. The bare rounded 
spot stands out conspicuously from amongst the sur- 
rounding hair. It is perfectly bald and smooth, with- 
out any scaliness. In some cases there are a few 
black points in the patch, which have been taken for 
broken-off hairs, but are reaUy the remains of hair- 
roots which have not fallen out. In some cases there 
wiU be a few straggling hairs remaining. It seems 
as if the patch was depressed and atrophied, but this 
^.ppearance is probably due to the fact that the bajr 



ALOPECIA AREATA. 107 

and roots have fallen out of the part. In color, the 
affected area in its earlier stages may be slightly red- 
dened from hypersemia, but in most of the cases that 
we meet with, it is white and polished. To the touch 
the skin seems soft and pliable. Sensation may be 
normal in the patch, but often somewhat blunted, as 
shown by the amount of stimulation the diseased 
surface will tolerate. 

The hairs at the margin of the patch at first, and if 
the disease is spreading, will be loose, dry, brittle, 
atrophied at the root and come out readily on slight 
traction. Later, and when the patch has attained its 
full development, they will be firmly seated in their 
follicles, and normal in appearance. 

Eecovery will be indicated by the appearance of fine 
lanugo hairs in the patch. These may fall out again 
to be followed by a new crop of white hair, which will 
remain and, growing stronger, develop into strong 
colored hairs. Kaposi says that, if the disease [has 
been severe and general, restitution of the hair will 
not take place; and that even in milder cases it may 
go no further than the production of lanugo hairs. 
The disease is comparatively rare. Neumann describes 
a form of this disease in which there is marked anaes- 
thesia of the scalp. 

Some of the French authors, judging from their de- 
scriptions, would seem to have an entirely different 
idea of alopecia areata than we have, and to have con • 
founded it with other diseases. Thus, Cazenave (-iS) 
describes cases in which a change in the color of the 
hair took place, and designates the disease vitiligo 
capitis. Gruby (214) says that the patches are covered 
with a whitish dust formed entirely of cryptogamia. 
Hardy considers the disease as having two stages: 
First, an early parasitic contagious stage; and second, 
a neuropathic stage in which the parasite has disap- 



108 DISEASES OF THE HAIR AXD SCALP. 

peared. Courreges (53) regards the disease as having 
three stages: First, one in which there is discoloration 
of the skin and fall of the hair, itching of the scalp 
and pityriasis. This stage is short. Second, the ap- 
pearance on the bald spots of dehcate downy hairs. 
This period may last for years. Thirdly, the period 
of recovery and growth of strong hair. Further, he 
makes two varieties of alopecia areata, namely: la 
pelade achromateuse, and la pelade decalvante. The 
first is the porrigo decalvans of Bateman, and the 
vitiligo de cuir chevelu of Cazenave It corresponds 
to our usual and typical form of alopecia areata. The 
second form is one in which a rapid fall of the hair of 
the whole head or body takes place, and corresponds 
to what we should regard as an unusually marked 
form of the disease. Courreges' views as to these di- 
visions are not pecuUar to himself, but are quite com- 
monly held by French authors. BAzm (190) affirms 
that true pelade (alopecia areata) is very rare, but that 
there is a false form which is often the consequence of 
tinea tonsurans badly treated or left to itself. 

The disease has a tendency to recur, and sometimes 
is hereditary. Thin (257) reports a case in which a 
father and three of his children had the disease; and 
Hardaway (216) has met with tvv^o cases in which 
relapses took place in the Spring of successive years 
and attacked new areas each time. 

Etiology. — The etiology of this disease has been a 
field of battle for many years, and dermatologists are 
divided into two great camps in regard to the question 
of its being parasitic or non -parasitic. The large ma- 
jority of observers are against the parasitic theory; 
thus of forty- two authors consulted as to this point, 
and they were taken Tvathout selection, fifteen were 
for the parasitic theory, and twenty-seven against it. 
Ill the first group were sucli rnen as Anderson, T-Fox^ 



ALOPECIA AREATA. 109 

Thin, Gruby, Bazin, Hardy, and Eichhorst; in the sec- 
ond group, Duhring, Kaposi, Neumann, Schwimmer, 
Michelson, Veiel, Vidal, Horand, Duckworth, Pye- 
Smith, Liveing and Wilson were found. Gruby (214) 
was the first to allege a parasitic origin for the disease, 
and in 1843 described the parasite, which he named 
''' Microsporon Audouini.^'^ Bazin, in 1862, brought 
forward the claim of '^ Microsporon Decalvans " to the 
honor of being the cause of the disease. Thin (529), in 
1881, described yet another fungus in this disease which 
he called ^'jBacfermm decalvans.^^ Von Sehlen (267) 
is the last investigator who .professes to have found a 
parasite in alopecia areata. 

It is true that a single positive result from the study 
of a disease is of vastly more value than many nega- 
tive ones, and we should have the etiology of alopecia 
areata settled upon a firm foundation if the positive 
results of those who believe that they have found a 
parasite were in accord. But they are not. Gruby 's 
cryptogamia are arranged so as to form a tube or 
sheath about the hair, and consist of trunks with 
branches and sporules. They commence to develop 
on the surface of the hair, 1 to 2 mm. from the epider- 
mis. T. Fox describes the fungus as occurring in the 
form of very delicate, waxy, mycehal threads. Mal- 
LASSEZ (228) describes the spores as spherical or ovoid 
highly refractive bodies, some double -contoured and 
some not, seated in the epidermic scales of the superfi- 
cial layers of the epidermis, and occasionally upon the 
hair. Thin (259) speaks of his fungus as minute round 
or elongated rounded bodies in the hairs, arranged in 
pairs in the long axis of the hair. 

Such disparity in the findings of the investigators of 
this disease, and the fact that many other well-trained 
and expert workers in pathological histology have 
sought for the parasite and have not found it, are iu 



110 DISEASES OF THE HAIR AND SCALP. 

striking contrast to what obtains in the other parasitic 
diseases of the skin. At present we are forced to ac- 
knowledge that there is not sufficient evidence offered 
to warrant us in regarding this disease as a dermato- 
mycosis. Besides the absence of proof of the presence 
of a parasite, the suddenness of onset of the disease, 
its occasional general appearance, and the want of any 
trace of fungous growth or debris upon the affected 
areas, are all against the parasitic theory. Dermato- 
mycoses are slow in development, usually appear 
primarily in a number of small foci, and do not involve 
the whole surface at once, and generally scales or 
crusts are present upon the diseased areas. 

The most probable cause of the disease is a tropho- 
neurosis. It is true that no nerve lesion has yet been 
demonstrated in connection with the disease. But the 
sudden onset of the malady, all the hairs in a given area 
being at one and the same time loosened, seems to 
indicate that some profound disturbance in the nutri- 
tion of the affected part has taken place, probably 
dependent upon some trophic nerve disturbance. The 
neurotic theory of the disease finds further support in 
the occurrence of periodic head-aches and disturbances 
of sensation before the outbreak; in the presence of 
anaesthesia in the patches to a greater or less degree; 
in its frequent occurrence in children who have unstable 
nervous systems; and in its following upon severe 
nervous shock, Uchermann (263) has reported a case 
of alopecia areata in a boy which followed a blow on 
the head with a stone, and involved the whole head, 
MiCHELSON (231) has met with a case following a fall. 
Tyson (262) has recently reported three cases of com- 
plete fall of the hair following rapidly upon nervous 
shock. MiCHELSON (231) also suggests that the disease 
may be due to a closure of the cutaneous vessels of 
the affected area, and consequent interference with 



ALOPECIA AREATA. Ill 

nutrition, the closure being due to a connective-tissue 
increase of the intima. It is possible that the neurosis 
may express itself in a constricting action upon the 
blood-vessels, either those going to the middle foUicle 
region or to the papilla, and a consequent preponder- 
ance in the productivity of one or the other region, 
and a fall of the hair. Joseph (p. 223) has recently 
produced in cats lesions exactly resembling alopecia 
areata in man, by cutting out the second cervical 
ganglia. 

The disease is comparatively rare. Bulkley met 
with it forty-six times in eight thousand cases occur- 
ring in New York city. It would seem to be rather 
more common in Glasgow, Anderson having had one 
hundred and fifty-three cases in ten thousand. It 
befalls both sexes, though it is more common in males. 
Children are often affected with the disease. They 
formed about one-sixth of Bulkley's patients. Ac- 
cording to his tables, the disease in the upper classes 
is most frequent between the ages of twenty and forty, 
no fewer than twenty-five out of thirty -five cases oc- 
curring between those ages. He met with it much less 
frequently in public than in private practice. I have 
met with the disease twenty-nine times in four thou- 
sand consecutive cases in dispensary practice. Of the 
patients, seventeen were males and twelve females. 
The majority of the cases occurred between the twenti- 
eth and fortieth year of age, namely, eighteen. There 
were ten patients under twenty years of age, and but 
one was over forty. The youngest was a girl of five 
years, and the oldest a man of forty- four years. 

It is not contagious, though Hillier (217) and others 
report cases occurring epidemically. This, however, is 
contrary to the experience of most observers. It has 
been seen in the same patient coincidently with ring- 
worm of the head, and probably such occurrences have 



112 DISEASES OF THE HAIR AND SCALP. 

led to mistakes in diagnosis. The ''tinea decalvans" 
of Tilbury Fox, in which perfectly bald circumscribed 
spots occur with parasites in the neighboring hairs, 
may have been of this kind. Liveing (226) thinks that 
it is just possible that trichophytosis may in some cases 
so interfere with the nutrition of the hair as to favor 
the subsequent development of alopecia areata. 
Alder Smith (79) draws attention to the fact that a 
patch of trichophytosis capitis may be changed into a 
perfectly bald, smooth place by the appHcation of an 
ethereal solution of boracic acid. Instances, such as 
those given by Tom Robinson (75), of the disease being 
apparently transmitted by means of hats or caps, w^ould 
seem to point strongly to the contagious nature of the 
malady, but are so very exceptional that they may be 
regarded as coincidences. 

The following are considered to be predisposing 
causes, viz.: The nervous diathesis; disturbances of 
the general nutrition of the body, as from recent con- 
stitutional syphiMs (Squire, 34 a); menstrual disorders 
(Nayler, 52); arsenic (Wyss, 272); parturition and 
pregnancy (Graham, 213). 

Pathology. — Hairs extracted from the margin of 
an advancing patch of alopecia areata show marked 
atrophic change, and are seen to terminate abruptly 
in a pear or club-shaped extremity. Sometimes a por- 
tion of the root sheath is attached to the plucked 
hair, sometimes not. As we approach the free end of 
the hair an oval swelling will sometimes be found ta- 
pering again towards the extremity of the hair, which 
is often spht. Duhring (202) draws attention to the fact 
that these changes differ from those found in senile 
alopecia only in the suddenness of their occurrence. 
Sometimes ampullary swelHngs are found near the root, 
composed of a concentration of granular pigment 
matter: and sometimes there are adherent foUicular 



ALOPECIA AREATA. IIB 

and sebaceous matters round the shaft. Below the 
swelHng a stricture is apparent, which again passes 
into the deeper bulb elements above the papilla and 
at the base of the sac. Sometimes bright refracting 
granules are seen investing the hairs, which are not 
easily removable by ether, and no doubt suggested the 
fungus theory, but are in reality fatty particles. The 
swelling of the cuticular scales of the hair simulates 
a fungus. DuHRiNG (202) says that what is described 
as the microsporon Audouini is an accumulation of 
an appreciable amount of sebaceous matter, broken up 
epidermic scales, and debris about the roots of the 
hair; further, that sebum when subjected to a reagent 
has a tendency to split and break up into fine particles, 
which adhere so closely and with such tenacity to the 
hair as to accurately resemble spores. 

All those who describe the parasite in this disease give 
exj)Hcit directions as to the preparation of the hair for 
examination, and lay great stress upon the difficulty 
of finding the fungus. Gruby (214) described the 
parasite as follows: The cryptogamia are arranged 
so as to form a tube or vegetable sheath about the hair. 
They consist of trunk, branches, and sporules. The 
trunks have an undulated form following the direction 
of the hair fibres, are transparent, and have a diameter 
of .002 to .003 mm. They bifurcate at times, giving 
off branches at an angle of thirty to fifty degrees. The 
branches are distinguished from the trunk by the 
sporules which accompany and cover them. The 
sporules are oval or round, the diameter of the former 
being 0.002 to 0.008 -mm., and of the latter 0.001 to 
0.005 mm. They are transparent, and do not contain 
molecules in their interior, and swell in water. These 
are the microsporon Audouini. They commence to 
develop at the surface of the hair, 1 to 2 mm. from 
the epidermis. They are first seen parallel to the axis 



114: DISEASES OF THE HAIR AND SCALP. 

of the hair, and spread by immediate contact from 
hair to hair. Bazin (190) gives a similar description. 
T. Fox (210) says the fungus occurs in the form of 
very dehcate waxy mycehal threads. Thin (259) found, 
after careful preparation, minute round or elongated 
rounded bodies in the hairs which resembled in shape 
and refractive power his ' ' bacterium foetidum. ' ' These 
he beheves are the cause of the disease, and names 
'^bacterium decalvans.^^ They were in position and 
arranged so as to show that they were distinct from 
the rows and aggregations of minute granules which 
are found in healthy hairs. They were found fre- 
quently in pairs, the long axis of each member of a 
pair forming a continuous line. Sometimes three 
were foimd end to end, with the appearance of one 
continuous sheath for the three. Malassez (228) de- 
scribes the spores as occurring in the epidermic scales, 
in the superficial layers of the epidermis, and occa- 
sionally upon the hair. According to him they are 
spherical or ovoid highly refractive bodies, not larger 
than 4 to 5 mm. They are double contoured and 
many smaU buds project from their circumference. 
Some smaller spores (2 mm.) were without the double 
contour, and some still smaller were simply spherical. 
They were found singly or in groups or chaplets. 
Yon Sehlen's (267) micrococci were found in the root- 
sheaths of the hair, but his description of the cases 
from which the hairs examined were obtained is so 
strikingly hke that of trichophytosis capitis that we are 
led to think that he made an error in diagnosis; and 
BoRDONi Uffreduzzi (193) has found micrococci iden- 
tical with these upon the roots of the hair of the nor- 
mal skin. 

The findings of the different observers vary amongst 
themselves so much that it is best to await further 
developments before deciding that the disease is para- 



ALOPECIA AREATA. 115 

sitic. It is noticeable that the different parasites 
described are all superficial to the skin in or upon 
the hair. This is not the way in which perfectly 
smooth bald patches could be produced; for that it is 
necessary that the hair papillae should be affected. In 
this connection it is interesting to note that Nystrom 
(237) found spores identical with those described by 
Malassez upon a napkin hung in a moist corner of a 
room, and therefore regards them as derived from the 
atmosphere. Michelson (234) has found on normal 
hairs by cultures the same cocci as described by Von 
Sehlen. He also found them on hairs taken from 
the edge of alopecia areata patches. Thus far his at- 
tempts at inoculation of these have been failures, and 
he regards them as being a normal condition. 

Dyce Duckworth (201) has recently had the oppor- 
tunity of examining a case of alopecia areata occurring 
in the person of a boy aged thirteen years who was 
drowned. The disease first came on when he was 
four years of age, and had gone and come several times 
since. After death portions of the scalp were caref uUy 
examined, and the results reported, as follows: There 
was found to be: 1. A distinct atrophy of the hair- 
foUicles and the sebaceous glands in connection with 
them. 2. Infiltration of the hair-follicles, specially 
their outer root-sheath, with a new round cell growth. 
This growth appeared to be perivascular, and tracts of 
it were foiuid in the middle layer of the corium lead- 
ing up to the papillary layer. 3. The hair follicles in 
the affected part were mostly quite atrophied, their 
nourishment having been cut off by the new growth. 
In some instances remains of the papillae were seen, 
but the capillary loops were infiltrated with the cell 
growth. In other instances the follicles appeared to 
be making efforts at repair by throwing out numerous 
digitations. 4. The vitreous membrane of the f oUicles 



116 



Diseases of the haik akd scalp. 



was in some cases hypertrophied. 5. The sweat glands 
were practically unaffected, though parts of their ducts 
were impHcated in the new growth. 6. No parasitic 
elements were found. 

Wagner and Schultze (248) have examined pieces 
cut from the hving scalp with negative result. 

Diagnosis. — The diagnosis is easy, as a rule, the dis- 
ease presenting so striking an appearance as hardly to 
be mistaken for anything else. As in psoriasis, the 
symptoms are so weU pronounced that students, once 
having seen a case, do not easily forget it. Some- 
times, however, it may be difficult to distinguish it 
from ringworm of the head, and it must also be 
diagnosticated from favus, from other forms of 
alopecia, and possibly from vitihgo. 



Differential Diagnosis from Trichophytosis Capitis. 



Alopecia Areata. 

1. Occurs suddenly -without 
antecedent lesion, and the patch- 
es often attain their full size at 
once. 

2. Patch usually perfectly cir- 
cular and does not contain 
"gna wed-off" hairs, scales, or 
crusts, but is perfectly smooth 
and shiny. 

3. Hairs about patch unalter- 
ed, though at times they may be 
easily extracted. 

4. Occurs only on hairy parts 
of the body. 



5. No parasite found, or at 
least none readily detected. 



Trichophytosis Capitis. 

1. Begins usually at one point 
by a small erythematous papule 
or patch, and spreads from it 
more or less slowly. 

2. Patch more or less circular, 
with broken and gnawed-off 
hairs in it, and floor covered 
with thick, grayish crusts or 
abundant scales. 

3. Hairs in and about patch 
are brittle, break easily when 
pulled on, and bend at an angle. 

4. Occurs both on hairy and 
non-hair}^ parts of the body; and 
patch will sometimes spread 
from non-hairy to hairy parts, 
or vice versa. 

5. Fungus found abundantly 
in ha r and scales. 



The two conditions are less easily distinguished 
when ringworm of the head has lasted some time, 
involves a large portion of the scalp, and is in an in- 
active condition. But even here there mil be more or 
less scahng, and an occasional broken-off stub of hair; 



ALOPECIA AHEATA. llV 

and careful search will discover the fungus in the hair 
or scales. 

Favus lacks the circular development of alopecia 
areata, is more disseminated, has the sulphur-yellow 
cup-Mke crusts characteristic of it, or else the scalp is 
covered with powdery scales. It developes slowly, is 
inflammatory in character, and leaves cicatricial 
patches where it has run its course. The microscope 
shows the fungus abundantly in scales, crusts, and hair. 

Alopecia Senilis and Praematura develop slowly, 
beginning either at the vertex and spreading forward, 
or at the forehead and spreading backward, involve only 
the upper middle region of the head, and take months 
or years to produce complete baldness. There is often 
a history of preceding disease of the scalp, such as 
seborrhoea. In alopecia areata the baldness occurs 
suddenly, occupies the lateral parts of the head quite 
as often as other regions, and generally there is no 
antecedent disease of the scalp. If it involves the 
greater part of the head, there will yet be the history 
of distinct patches at the begining. 

Sometimes syphilitic alopecia will present appear- 
ances very much like alopecia areata. In syphilis we 
meet with two forms of baldness, one occurring as the 
result of the cachexia of the disease, and the other from 
the absorption or breaking down and ulceration of a 
syphilide. The first form sometimes resembles a severe 
case of alopecia areata, affecting more or less generally 
the whole head, and causing great loss of hair. It 
differs from it in giving a characterisfcicaUy ragged 
look to the head, and in showing no tendency to the 
formation of circles. The history of the case will aid 
in making the diagnosis. Should there be any cuta- 
neous manifestations of syphilis present, the decision 
will be easily reached. The second form of alopecia 
syphilitica resulting from ulcerating lesions is diff'er- 



lis DISEASES OF THE HAIR AXD SCALP. 

entiated from alopecia areata by its history and by the 
cicatricial tissue present. 

Bald spots arising from burns and other injuries to 
the scalp should offer no difficulty in diagnosis; their 
history and cicatricial appearance show their origin. 

Vitiligo should not be confounded with alopecia 
areata. It is a disease affecting only the color of the 
hair. 

Prognosis. — The disease tends to recover spontane- 
ously, especiaUy in young people. In older people 
the prognosis is not so good. Neumann (27) says the 
outlook in the anaesthetic form is bad; and the serpi- 
ginous form is considered by Squire (34a) to be of less 
favorable prognosis than the circular form. Cases of 
general alopecia, especially those coming on suddenly, 
are more grave than the circumscribed cases. The 
duration of the disease is variable. Eecovery has 
taken place in six weeks, but this is exceptional. 
From six months to two years may be given as a rea- 
sonable time in which to look for recovery. The pa- 
tient should be apprised of the tendency the disease 
has to relapse. 

Treatment. — Most of the sufferers from this malady 
exhibit some indication for the exhibition of tonics. 
When occurring in children they will often be found to 
be anaemic. They should be taken out of school and 
allowed plenty of air and exercise until they attain to 
a better degree of .health. Cod-hver oil, iron, phos- 
phorous, arsenic, and quinia are the drugs most indi- 
cated as tonics. The use of phosphate-bearing food 
is advised by some, as oatmeal, cracked wheat and 
the hke. We should endeavor to place our patients 
under the best possible conditions, to reheve them as 
far as may be from aU sources of anxiety, and to 
alter anything that may be wi'ong on the side of the 
general economy. 



ALOPECIA AREATA. 119 

The local treatment consists in stimulation of the 
scalp. In the begining of treatment it is well to re- 
move by epilation all the loose hairs about the margins 
of the patches. The best method of effecting this is 
by pulling the hair between the thumb and an ordi- 
nary spatula or stout card held in the hand. 

For stimulants, carbolic acid; tincture of cantharides; 
cantharidal collodion; tincture of nux vomica, vera- 
trine, capsicum, phosphorus, or aconite; sulphate of 
quinine; strychnine; liquor ammoniae fortior; sulphur; 
bichloride, yellow sulphate, and oleate of mercury; 
croton-oil and castor-oil, each and all have their advo- 
cates, and are used either separately or two or more 
of them combined. As the diseased scalp will bear, 
as a rule, a good deal more stimulation than the healthy 
scalp, we must regulate the strength of our chosen 
stimulant solely by the amount of reaction it causes. 
Thus, liquor ammoniae fortior, in full strength, may 
be freely apphed to the scalp, and its use persisted 
in for weeks without apparent over-irritation of the 
scalp. As our object is simply stimulation, I can see 
no reason for combining any of the above-mentioned 
stimulants, excepting that the castor- oil may be used 
as an eligible excipient for some other remedy. We 
may choose as a vehicle for the stimulant either an 
oil, an ointment, lard, vaseline, or water. It is weU 
to change our stimulant from time to time. 

Good results have been reported from the use of 
electricity, the galvanic current being used with one 
pole at the nape of the neck, and the other brushed 
over the affected parts; and G. H. Fox has reported 
improvement in some cases treated with static elec- 
tricity. Hypodermic injections of \ to yV grain of 
the muriate of pilocarpin every few days are well 
spoken of by some observers. 

Sulphur ointment is advocated by Thin (i\')8), and 



1^0 DISEASES OF THE HAlR AND SCALP. 

he has published a series of excellent results from this 
treatment, maintaining that these results are due to 
the action of the ointment as a parasiticide. 

The treatment by blistering has in some cases pro- 
duced rapid results. For this purpose either croton- 
oil or cantharides may be used. Thus, Horand (218) 
advises painting the bald spots with croton-oil, cov- 
ering -with cotton, and wearing a hood over all. If 
ulceration is caused, the part is to be dressed with 
olive-oil. When healed, the application of the croton- 
oil is to be repeated. This method of treatment is to 
be continued till the hair grows. Vidal (266) recom- 
mends the following: If the subject is a child, the 
whole head is to be shaved. If the patient is older, 
the scalp is to be shaved for half an inch around the 
bald spot. Now apply a bhster, which should never 
be larger than a twenty-five cent piece, to each bald 
area, putting it on in the morning and taking it off 
when the epidermis begins to rise. If a large bleb 
forms, it should be opened. Powder the blisters with 
starch and cover with linen. If there are numerous 
bald spots, apply the blisters to them successively. 
If the hair does not grow after thorough bhstering, 
repeat the operation as soon as the effects of the first 
apphcation have disappeared. If blisters are not well 
borne, use sinapisms. When the hair begins to grow, 
shave, and rub in, every morning and evening, a lo- 
tion of 



Liq. ammon. 


. 


4. 


Alcohol, .... 


, 


. 16. 


Decoct, fohae juglandis, . 


, 


. 120. 


M. 







For alopecia areata of the face he uses bhsters in some 
cases. Generally he has the part shaved every day 
and uses frictions of tincture of cantharides, either 



ALOPECIA AREATA. 121 

pure or with one-fifth to one-sixth of the tincture of 
rosemary. 

CouRREGES (53), a believer in the parasitic origin of 
this disease, directs that the head be washed twice a 
day with a lotion of 

Chloride of ammonia 

Bichloride of mercury, . . aa 1. 

Water, .... . 500. 

M. 
or that the following ointment be applied twice a day; 

Yellow sulphate of mercury, . 1. 

Lard, 30. 

M. 

This he does to destroy the parasite. To stimulate the 
growth of the hair he advises shaving once or twice 
a week. If there is only one patch or but two or 
three, these and their immediate neighborhood are to 
be shaved. Should there be many patches, the whole 
scalp is to be gone over with the razor. 

Cottle (52) directs that the aifected area be painted 
with acetic acid until the scalp whitens, and then 
sponged off with cold water. This is to be repeated 
every three or four days; and in the intervals an oint- 
ment composed of three drachms of balsam of Peru in 
one ounce of benzoated lard is to be applied. 

GuiBOUT (14) recommends shaving, frictions with 
camphorated alcohol, and bathing very often during f 
the day with equal parts of camphor and sulphurous 
ether. 

A.E. EoBiNSON (33) speaks favorably of inunctions 
with a ^ve to ten per-centum ointment of chrysarobui 
preceded by vigorous friction with soap and water 
and a rough towel. 

Lassar reports satisfactory effects in two cases from 
the use of corrosive sublimate lotions, followed by dis- 



122 DISEASES OF THE HAIR AND SCALP. 

iiifectant oils such as salicylated or carbolised oil. In 
my last cases of alopecia areata I have used a solution 
of corrosive subhmate, not on account of its parasiti- 
cide quahties, but solely for its stimulating effect. 
The strength of the solution used was three parts of 
the bichloride of mercury in one thousand parts of 
water, or say one grain and a half to the ounce. This 
was apphed once or twice a day, and has given satis- 
factory results. One patient, a man aged thirty years, 
came to me last May with a number of perfectly bald 
patches of alopecia areata, some of which had lasted 
for more than a year. He was given the bichloride 
lotion just indicated. In fourteen days lanugo hairs 
had begun to grow in aU the patches, and in three 
months they were completely covered with vigorous 
though white hairs. He had used the lotion alone and 
shaved the patches once in two weeks after the hair 
had begun to grow. Unfortunately, this is the only 
case in which I have been able to watch the effect of 
this treatment. 

In a few cases I think that I have produced benefit 
by using a pomade oijaborandi, made by boihng down 
the fluid extract to one half its volume and adding 
this to lard in the proportion of one of the jaborandi 
to four of the lard. This is to be thoroughly rubbed 
in tmce a day. In the first case, of the recurrent type, 
the hair in two relapses retmrned under this treatment 
in the course of ten weeks. But it had no effect in 
preventmg the formation of new patches. In the 
second case, occurring in a child with chorea, after the 
use of various other remedies for three months, the 
spots conthiuaUy growing larger, the jaborandi was 
used, and in ten weeks the disease had ceased spread- 
ing, and the hair was growmg on every patch. In a 
third case, affecting the mustache of a medical student, 
its use was foUowed in seven weeks by the appearance 



ALOPECIA AREATA. 123 

of new hairs in the patch, shaving being practiced at 
the same time. In these three cases, the return of 
the hair took place some six or seven months after 
the beginning of the disease. Pilocarpine may be 
substituted for the jaborandi in the strength of two 
or three grains to the ounce. Lanolin is a good ex- 
cipient for it, as it penetrates the skin more readily 
than lard. It should be diluted with one or two 
drachms of castor-oil to the ounce to make it more 
fluid, and the whole may be perfumed with one or 
two drops of oil of roses. 

MiCHELSON (40), in Ziemssen^s Handhuch (vol. II. pg. 
139), speaks highly of the use of warm salt-water baths 
(five per cent, salt) three times a week and of twenty- 
five minutes duration. In conjunction with this, twice 
a week the faradic current is to be applied to the scalp 
with a brush electrode for ten minutes. Upon the 
days when the baths are not used, the scalp is to be 
rubbed w4th a stronger aqueous solution of salt. 

As alopecia areata has a tendency to get well of it- 
self, in its own good time, it is hard to determine how 
far our remedies are active in hastening a cure. So 
good an authority as Kaposi (19) has said that reme- 
dies have httle if any effect on the disease. 

Even after the damage to the hair has apparently 
been made good, it is advisable to counsel our patients 
to use some mildly stimulating lotion to the scalp, and 
to pay particular attention to the hygiene of the hair 
for some months. 



CHAPTEE VIII. 

ATROPHIA PILORUM PROPRIA. 

Atrophy of the hair exists under two forms, namely: 
Fragihtas crinium, and Trichorrhexis nodosa. In 
both the hair shaft is easily friable and splits, or breaks 
off of itself or upon the sHghtest traction. The two 
forms differ, in that in the first there is only a simple 
or compound cleavage of the hair; while in the second, 
there is also the formation of nodular swellings along 
the hair shaft, and a brush-like breaking up of the 
elements of the hair. 

Fragilitas Criotum. 

Synonyms : — Scissura pilorum. — Trichoptilosis. — Tri- 
choxerosis. 

Definition. — That condition of the hair in which it 
is more or less dry, and its shaft is split either at its 
end or in its continuity. It may be symptomatic or 
idiopathic. 

1. Symptomatic Fragilitas Crinium. — This form is 
by far the most common variety of the disease, and 
needs httle comment here. In the parasitic diseases of 
the hair — trichophytosis capitis et barbse, and favus — 
the hair becomes dry, brittle, and broken off. This con- 
dition of the hair is always met with in these diseases 
and is a diagnostic symptom. In any disease of the 
scalp if of long continuance we meet with dryness and 
brittleness of the hair, and this is notably the case in 
seborrhoea sicca and eczema. In any general consti- 
tutional disease, as in fevers, phthisis, scrofula, and 
the various cachexise, in which there is a lowering of 



ATROPHIA PILORUM PROPRIA. 125 

the nutrition of the body, the hair sympathizes, loses 
its lustre and suppleness, and takes on the condition 
of fragilitas crinium. 

Etiology. — The causes of this condition are easily 
discoverable. In the parasitic diseases, the fungus 
grows in and about the hair and its root, and by its 
presence causes a degeneration of the hair. In favus, 
a complete destruction of the hair-foUicle and papilla 
takes place. In seborrhoea and eczema the hair be- 
comes dry, because it is deprived of its proper lubricant, 
on account of alterations in the sebaceous matter, and 
because its nutrition is interfered with. In the gen- 
eral constitutional diseases, mal-nutrition is the cause 
of the fragihty of the hair. 

Treatment. — This will depend upon the disease 
which the condition accompanies, and wiU be given 
in the proper chapters. We now turn to 

2. Idiopathic Fragilitas Crinium. — In this form, 
without any apparent disease of the scalp or underly- 
ing skin, and often without any general constitutional 
disease, the hair becomes dry, brittle and split. The 
cleft in the hair may be either at its free end, in the 
continuity of the shaft or even within the bulb. When 
beginning at the free extremity, it may run for some 
distance up the shaft. When it begins at the exit 
from the follicle, the cleft extends for a variable dis- 
tance, it may be for the whole length of the shaft. In 
this case and in the case in which the cleft occurs in 
the middle of the shaft, the filaments will either sepa- 
rate widely or hold together. When the split occurs 
at the end, the filaments wiU either separate from 
each other more or less, or will curl up upon them- 
selves. The disease occurs most often upon the 
scalp, the beard being the part next most frequently 
affected. It is by far most commonly met with in 
the long hair of womexa. The affected haivs ai'^ 



126 



DISEASES OF THE HAIR AND SCALP. 



\ 



Tjv 



scattered here and there throughout the general 
mass of hair, which may appear nor- 
mal or be somewhat drier than it 
should be. In some cases all the hair 
of a certain portion of the scalp is 
found broken up into filaments. Be- 
sides the sphtting, the affected hairs 
may show no other abnormahty, al- 
though they are often irregular and 
uneven in their contour. 

In a case reported by Duhring (280), 
which is unique, the beard was the 
region affected. In it the hair began 
to split within the bulb, and the pro- 
cess was attended by so great an irrita- 
tion of the f oUicles as to cause f olhcular 
papules and pustules. "The hairs," 
he says, ''were very bristly; sometimes 
they were of good length, sometimes 
short, sometimes thicker than normal, 
sometimes abnormally slender, some- 
times straight, sometimes crooked. 
Sometimes they came out easOy when 
puUed upon, or fell out of themselves, 
and sometimes they were quite fast in 
the foUicle and broke off, leaving the 
root behind, when epilation was at- 
tempted." 

Pathology. — In most cases the 
microscopical examination shows noth- 
ing of importance, apart from a lit- 
tle irregularity in the contour of 
the shaft, and the spht at the end 
with its diverging filaments. The 
bulb of the hair may be normal or 
atrophied. In Duhring's (280) case. 



A 



m 



m 



i 



Splitting of the end 
of a hair. T.n. Trichor- 
rhexis uodosa. S.p, 
Scissura pilorum. 
CMicbelson.) 



ATROPHIA PILORUM PROPRIA. 127 

there were marked atrophy of the hair-bulbs and 
fissure of the hair-shaft beginning within the bulb, 
separation of the segments taking place at the 
bulb or at varying distances beyond it. The corti- 
cal substances presented a dry and brittle look in the 
narrowed portions, and a spongy luxuriant appearance 
in the thickened parts of the hair. The medulla was no- 
where normal, but was present here and there in 
broken tracts. 

Etiology. — The cause of this disease is yet undeter- 
mined. Kaposi (19) would explain the sphtting of the 
long hair of women upon the theory that it is due to 
the distance of the distal extremity of the hair from its 
source of nourishment — the hair-root or papilla. This 
is not an altogether satisfactory explanation, as it is by 
no means always the longest hairs which present the 
cleft end. Nor would this theory account for the 
disease as met with in the short hairs of the beard. 
Gamberini (59) would find its cause in want of due care 
of the hair and in allowing it to grow to excess. But 
as in the symptomatic form, there is some evident dis- 
ease affecting the nutrition of the hair, and as in some 
of the idiopathic cases, there is an atrophy of the bulb; 
we can feel sure that the idiopathic form also is depend- 
ent upon some interference with the nutrition of the 
hair. 

Treatment. — In all cases the scalp or underlying 
skin should be kept in good condition, as is directed 
in Chapter III. When the disease occurs in the 
long hair of women, besides attention to the scalp 
and the brushing and combing of the hair, the cleft 
ends should be carefully cut off just above the 
split. If the disease occur in the beard it shoukl 
likewise be regularly clipped, and all rough rubbing 
and handling of it should be avoided. In shaving, we 
have a last resort by which th(^ deformitj^ maj^ h^ 



128 DISEASES OF THE HAIR AND SCALP. 

removed, and possibly after a time the hair may grow 
normally: but this should be ordered only in very 
aggravated cases in women, as it is an heroic plan of 
treatment for them, and milder measures will gener- 
ally be sufficient. In all cases we should strive to cor- 
rect any thing that we find wrong in the health and 
well-being of the patient. 

Trichorrhexis Nodosa. 

Synonyms: — Trichoclasia; Trichoptylose; Tinea no- 
dosa; Piedra; Clastothrix; Tricho-syphilis. 

Definition. — Trichorrhexis nodosa is that condition 
of the hair in which nodular sweUings occur along its 
shaft and the hair breaks easily, usually through one 
of the nodes, and exhibits a peculiar brush-hke spread- 
ing out of the fibres of the broken-off hair, while the 
under-lying tissues are normal. 

Under this heading are grouped here three abnor- 
mahties or diseases — conditions of the hair which have 
two features in common — that is, that the hair-shaft 
suffers a lesion of continuity, and is deformed by the 
presence of nodular swelhngs. These three abnormali- 
ties are, trichorrhexis nodosa, which is a non-parasitic 
disease affecting chiefly the hair of the beard; piedra, 
a fungoid growth met with, as far as reported, only in 
the United States of Colombia; and tinea nodosa, a 
parasitic disease which may be found in any country. 
We wiU consider each separately and begin with the 
typical disease, 

T'richorrhexis Nodosa. — This disease was first de- 
scribed by Beigel (276) in 1855, under the title '' Auf- 
treibung und berstender Haare." Wilks (30y) recog- 
nized the disease in 1852, but did not publish an account 
of it until 1857. Wilson (311) asserts that he described 
it in 1849 in his book ^^ Healthy Skin " under the title 
pf ''fragiUtas crinium," and proposed the nanje qJ 



ATROPHIA PILORllM PROPRIA. 129 

^^ clastothrix " for it. In 1867 he exhibited to the 
Eoyal Medical and Chirurgical Society of London, 
specimens of what he called trichosyphilis of the beard 
and whiskers, which he considered as a disease distinct 
from fragilitas crinium. This was probably a case of 
trichorrhexis nodosa. Eichhorst (281) reported a case 
in 1858; since then various authorities have met with 
the disease and published cases of it. Kaposi was the 
first to propose for it the name of "trichorexis no- 
dosa," which has been accepted by the profession as 
the proper name for the disease. The spelling, how- 
ever, has been slightly changed, and it is now spelt 
either as ^' trichorhexis " or ^'trichorrhexis." We 
have adopted the latter style as it is the one used by 
the best writers of the German school. The disease 
is rare. Bulkley met with it but four times in eight 
thousand cases. 

Symptoms. — The disease comes on without any ante- 
cedent symptoms, the patient first noticing upon 
handling his beard that the hairs when pulled through 
his fingers, feel irregular and knotty, or else that the 
hair breaks easily and the beard looks ragged. If we 
examine the beard we find, along the hair-shaft, one or 
more whitish or grayish, shiny, transparent, nodular 
sweUings, looking not unlike the nits of pediculi, but 
more oval and evenly involving the whole circumfer- 
ence of the hair. Should the hair be red, the color of 
the nodes may be black. The number of nodes upon 
a single hair varies from one to five, and their diameter 
varies with that of the hair, being greater in the coarser 
than the finer hair. The nodes occur nearer the distal 
than the proximal end of the hair, and usually in the 
upper third of its length. The hair is exceedingly 
brittle and fractures upon slight traction, as on comb- 
ing, or spontaneously, the fracture taking place almost 
invariably through a node, and the hair fibres of the 



ISO DISEASES OF THE HAIR AND SCALP. 

broken ends separating like the hairs of a paint brush. 
Very rarely the fracture is internodular and the ends 
pointed. Sometimes the hair does not entirely break 
off, but the fibres splinter about the node, and the 
appearance presented is like that seen when two small 
paint brushes are pushed together, end to end. The 
fracture is usually transverse through the node, but 
sometimes, if there is an excessive amount of medulla 
present, it is longitudinal. 

Sometimes the hair has an irregular contour and is 
frayed along its entire length. When many hairs are 
affected, there will always be many frayed- out ends, 
and the beard will look as if it had been singed. The 
hairs are usually firmly fixed in the f oUicles, and the 
disease exists for many years with no tendency to the 
production of alopecia. 

The disease, in nearly all the reported cases, affected 
the beard, and therefore occurred in men; but it does 
occur at times in the scalp-hair and also in women. 
Thus W. G. Smith (303) reported a case which occurred 
in the scalp- hair and was peculiar in that the fracture 
took place in the internodular portions, and the ends 
of the broken hairs were not frayed out. There was 
also one nodose hair found amongst the pubic hair. 
MiCHELSON (40) believes that the condition is far more 
frequent in the scalp -hair than is supposed, and that 
the reason it is most frequently observed in the beard 
is because the hairs of that part are of larger diameter, 
and allow the condition to be more readily seen. On 
thin hairs the little nodes can be more easily felt than 
seen, indeed they can be hardly distinguished by the 
naked eye. He has met with the disease many times 
in cases of various forms of alopecia. 

Devergie (279) has also reported a case that oc- 
curred in the scalp -hair of a woman. 

Etiology. — The cause of the disease is obscure. 



Atrophia pilorum propria. 131 

Beigel (276) believed that it was due to an accumula- 
tion of gas within the substance of the hair, which, 
exercising pressure from within, first gave rise to the 
bulbous-formed swelliug, and ultimately burst the 
hair. Wilks (310) and Wilson (311) look to nutritive 
debility for an explanation of the malady. Eich- 
horst's (281) theory is, that the swellings are caused 
by fatty infiltration of the medulla, taking place at 
certain points, and that the splitting is purely acciden- 
tal, the result of pulling, in brushing and combing the 
hair. He thinks it probable that a swelling of the 
medulla first occurs that causes a bulging outwards of 
the cortical substance till it finally bursts and breaks 
asunder. 

So much for the earher theories. Of more recent 
date are those of Schwimmer, Startin, Pye-Smith, 
Kohn, Pincus, Wolfberg and Michelson. Schwimmer 
(301) says that the disease is a nutritive disturbance, 
probably a tropho-neurosis. Startin (305) holds that 
it is due to a degeneration of the medulla, a consequent 
rapid accumulation of cells at one point, and eventually 
a bursting open of the hair. 

Pye-Smith (289) regards a gradual drying of the cor- 
tical substance, and a consequent loss of coherence of 
its constituent fibre cells, as the cause; this being fol- 
lowed or attended by the breaking up into a granular 
material and swelling of the cells of the medulla, and 
finally a rupture of the cortex, there being nothing 
left to hold it together. S. Kohn (286) beheves that 
the process is analogous to the splitting of the long- 
hair in women, and is to be considered as an atrophy 
of the medulla taking place at different points, or as 
a partial disappearance of the same. Pincus (296) 
regards the disease as in part due to an interference 
•with the nutrition of the hair and in part to a deficient 
action of the sebaceous glands. Wolfberg (312) puts 



132 btSfiASES 01^ I^HE HAlR AKf> SgALP. 

forth the view that repeated mishandling of the thick 
medullated hairs of the beard, as in violent rubbing 
in drying after washing, is sufficient to cause the dis- 
ease in many people, and in this way he has designedly 
produced appearances microscopically identical with 
those of trichorrhexis nodosa. He believes this to be 
the only cause of the disease, and gives the following 
four reasons: 1. The anatomical appearances. The 
hair outside of the nodes is perfectly normal. The 
same appearances can be produced mechanically, and 
the disease occurs often in diseases of the beard which 
are itchy and hence cause it to be much rubbed. 

2. Location. It occurs most always in the strong 
medullated hair of the beard, the node formation being 
favored by the central canal. These appearances are 
difficult of production in fine non-medullated hairs. 

3. Because the explanations heretofore offered are 
not sufficient. 4. The obstinacy of the disease to 
treatment. This is easily explained, because it has 
consisted in rubbing the beard with irritating sub- 
stances. Sherwell (302), in his case, suspected a some- 
what similar cause on account of his patient's habit of 
rubbing cologne water into his beard; but subsequently 
he abandoned the theory. Michelson (40) looks upon 
abnormal dryness of the hair-shaft as the cause. 

We have thus ten different views expressed in re- 
gard to the cause of this singular affection. To choose 
any one as the true cause, would be unwise at present. 
The disease is not parasitic. This I beheve is the unan- 
imous testimony. Cheadle and Morris (278) have, 
it is true, reported a case to which they gave the name, 
amongst others, of trichorrhexis nodosa, but it was so 
different in its appearances from the disease in ques- 
tion, that we should rather call it "tinea nodosa." It 
does not seem to depend upon any diathesis, nervous 
or otherwise. Anderson (274) has reported one case 



Al^nOPHlA. PlLORtfM PROPRIA. 133 

which shows an hereditary influence. The disease in 
his case was congenital or nearly so, and could be 
traced back as far as the great grandmother. Those 
members of the family who had what they called 
''weak hair," were almost invariably of dark com- 
plexion. He gives the following " family tree," those 
marked with an asterisk (^) having " weak hair." 
(By this term is apparently meant hair that splits 
easily.) 

Mr. L. Mrs. L.* 
Mrs. B.* 
Robert, James, John,* David, William, Thomas,* Samuel. 



Marion, James,* Jane,* John, John, William, James,* Thomas, 

Mary,* Margaret,* Thomas.* | William.* 



Thomas, James,* Walter, Margaret.* Mabel,* Maud. 

I have met with but two cases of the disease. Both 
occurred in men and in the beard; and both patients 
were in the habit of handling the beard. As far as 
these cases are concerned I would be inclined to 
adopt Wolf berg's theory. The fracture of the hair is 
probably always due to mechanical causes. 

Pathology. — Beigel (276), who first described the 
disease, found minute globular bodies in the shaft of the 
hair which he took to be air-globules. Wilson (311), 
in his case of syphilitic degeneration of the hair, which 
was probably a case of the disease we are now discuss- 
ing, observed ''the diseased portions of the hair look- 
ing as if composed of a dark cylinder enclosed in a 
transparent envelope. Closer examination showed 
that the fibrous structure of the hair was lost, and 
its place occupied by a dark gummous-looking sub- 
stance. The essential peculiarity of structure of the 
diseased hair was arrest of development of the fibroiis 
portion at its cellular stage, the dark cyHnder which 



13 J: DISEASES OF THE HAIR ANB SCAL]?. 

formed the bulk of the diseased part being composed 
of large and small nucleated cells commingled with 
pigment matter, irregularly formed air-cells and frag- 
ments of crystahne substance." Eichhorst (281) saw 
"in hairs which were examined dry or in glycerine, 
that the individual fibres of the cleft hair were in 
places covered with line ghstening kernels. As these 
were not seen in preparations in Canada balsam and 
in turpentine, and as they were colored very black by 
hyper-osmic acid, they were doubtless fat drops. The 
further the swelling had proceeded, the less were they 
seen. The nodes were exclusively on the meduUa, the 
cells of which could be traced into the spindle-formed 
broken-up nodes, and appeared unaltered. But when 
hquor potassse and hyj^er-osmic acid were used, the 
meduUa ceUs were seen to be overladened with drops and 
masses of f at. " Wilks found, interspersed in the broken 
fibres, a few dark granules. Such were the findings of 
the earher investigators. Now let us turn to the more 
recent investigations and see what they teach us. 
PvE-S^nTH (298), in 1879, reported upon certain speci- 
mens of the disease as follows: "First stage; hair 
swoUen in fusiform nodules at intervals of a few hnes. 
Later, the cortical layer has begun to spht up and to 
separate transversely. In the more advanced cases a 
fine, granular material oozes out from the medullary 
portion. Lastly the hair breaks across leaving the 
brush-hke broken end formed by the frayed-out cor- 
tical fibres. Under a high power the exuded material 
appears as a uniform, finely granular substance. This 
has some resemblance to fish roe and might be mis- 
taken for sporules. There is no vegetable substance 
present. It is not probable that a development of gas 
causes the hair to spht. Apparently the cortex be- 
comes more and more dry, its constituent fibre-cells 
become less coherent, the medulla cells break up into 



ATROPHIA PILORtJM PROPRIA. 135 

this granular material and swell, till the rupture of 
the cortex is complete, and nothing remains to hold 
the hair together. There is no fatty degeneration 
present." 

S. KoHN (286), in 1881, writes: ''The httle clear 
bodies on the outer filaments of the split nodes, which 
are not altered by different methods of handling, shut 
out the parasitic nature of the disease, because they 
are only occasionally met with, never in the nodes nor 
other parts of the hair, and because they are out of 
all proportion to the disease. They are merely deposits 
from the outer air. The theory of atrophy has sup- 
port in the following microscopic appearances: In 
treating the hair- shaft with concentrated caustic potash 
or acetic acid, a swelling of the medulla is caused. This 
swelling we have never found in a node, but only in 
the beginning stage of the disease when no node could 
be seen. In those places where there are nodes, there 
is no medulla. The nodes under the microscope ap- 
pear as brush-like masses of split-up fibres. The fibres 
are partly directed outwards, and in part, the opposite 
fibres are shoved into each other. If the hair is broken 
off, we will find the remaining portion looking like a 
brush with its fibres spreading outwards. Between 
the stage of swelling of the medulla and the stage in 
which the broken node is met with, there is a stage in 
which holes are formed in the cortex. One sees plainly 
that the single cells of the cortex are loosened and be- 
ginning to fall apart. Transverse sections of the nodes 
show a part of the medulla replaced by air. " Michel- 
son (40) says, in Ziemssen's Handbuch, Vol. XIV., 
''In some places on the hair there is the appearance 
as if two brushes were pushed end to end; at a little 
distance from them the sliaft is split into several 
fasciculi, whose ends are frayed and i)resont n broom- 
like appearance. As a rule, the partial longitudinal 



1S6 DISEASES OF ffiE HAIR AND SOALP. 

splits are very nearly in the middle of the shaft, and 
if any medulla is present, it will be destroyed. Some- 
times, however, the hair splits into a larger fasciculus 
embracing the medulla, and into one or more smaller 
fasciculi. The affected part of the hair, already de- 
prived of its cuticle, bursts, and perhaps, with its 
fibres spread out in all directions, forms an admirable 
net to catch atmospheric dust. All sorts of particles 
are deposited, and sometimes caught so fast that 
they can not be dislodged by any mode of handhng. 
Specially striking are the dark, sharp-cornered coal- 
particles, and the blue ultramarine grains. A good 
deal of air finds lodgment also in the splits and holes. 
In the microscopical examination, this air wiU be more 
or less rapidly expelled from the hair by the fluid me- 
dium, and the appearance thus caused was the founda- 
tion for Beigel's theory of the development of gas 
within the hair, as the cause of the disease. We have 
never found any parasite present. Many hairs in the 
neighborhood of the affected hairs present an atrophic 
appearance." Hans Hebra (16) describes the hair 
roots as ''presenting a shrunken appearance, and ap- 
proximating to the size of the shaft." 

From consideration of these various microscopical 
appearances, we learn that there is first a swelling of 
the shaft, forming the node; then a transverse fracture, 
taking place through the node, combined with a spht- 
ting up of the hair-fibres; and lastly a lesion of con- 
tinuity occurs, and a brush -like end is presented by 
the broken hair. Further, in the node there is no 
medulla present. Michelson, Pye- Smith, and Wilson 
seem to find the beginning of the disease in the cortical 
portion of the hair; while Kohn, and Eichhorst, regard 
degeneration of the medulla as the first step in the 
process. The hair-roots are either unchanged or else 
slightly atrophied. 



ATROPHIA PILORUM PROPRIA. 137 

Lesser (288) has reported a case of " ringed hair " 
which presented the appearance of trichorrhexis no- 
dosa, excepting that, in his case, the fracture always 
took place through the constricted portion, which he 
believes to be the diseased part. The beginning of the 
fracture in his case was marked by a transverse break- 
ing of the cuticle, which often ran in a circular manner 
quite around the hair, and the raised epidermis formed 
a sort of collar. In a case of W. G. Smith (303), the 
fracture likewise occurred in the internodular por- 
tions. In parasitic diseases of the scalp, the appear- 
ances of trichorrhexis nodosa are not infrequently ob- 
served. 

Treatment. — Thus far aU modes of treatment have 
proved very unsatisfactory. All sorts of applications 
have been made to the affected parts, generally of a 
stimulating character, and particularly the various 
forms of mercurials, but without curative effect. Gam- 
BERiNi (69), in his book on the hair, recommends 
eifcher bathing the part with a lotion, composed of 15 
grammes of subcarbonate of potassium to 150 grammes 
of dilute alcohol (say 3 drachms to 1 ounces) ; or using 
inunctions of tannic acid or oil of cade. Schwimmer 
(301) advises that an ointment composed of a half 
gramme (gr. vii) of oxide of zinc, 1 gramme (gr. xv) 
of washed sulphur, and 10 grammes ( 3 ijss) of simple 
ointment, be rubbed in morning and evening. 

But the chief reliance is placed upon shn ving, with 
the hope that it wiU stimulate the nutrition of the hair, 
and that after a time the hair will grow in a proper 
manner. Wolfberg (312) founds his treatment upon 
his theory, and advises that the hair be left entirely 
alone. As other treatments have failed of doing any 
good, it would seem worth while trying this expectant 
plan in cases in which handling the beard is a possible 
etiological factor. 



138 DISEASES OF THE HAIR AXD SCALP. 

We will now pass to the consideration of the second 
form of nodose disease of the hair, viz. : 

PlEDRA. 

The best description of this is given by Malcolm Mor- 
ris (293) in his paper upon the subject reported in the 
Transactions of the Pathological Society of London, 
1879, vol. XXX., page 411: also in the Lancet, 1879, x., 
407. It is upon this paper I mainly rely in the follow- 
ing accomit of the disease, as from its rarity I have 
not had an opportunity to study it. 

Description. — Piedra is said to occur only in Cauca, 
one of the United States of Colombia, and was first 
described in 1874 by Dr. N. Osorio of the University 
of Bogota. It consists in the occurrence, along the shaft 
of the hair, of from one to ten small dark-colored nodes 
which are very hard and gritty, and rattle hke stones 
when the hair is combed or shaken. The stony hard- 
ness of the nodes gave the disease its name, which in 
the Spanish language means ' ' stone. ' ' These nodes 
are always placed at irregular intervals along the hair- 
shaft, and are first met with at about half an inch 
from the point of exit of the hair, the root being 
unaffected. The disease occurs most frequently in 
women, men being but rarely affected, and it is the 
scalp-hair alone which exhibits the disease. It is non- 
contagious and seems to be met with only in warm 
valleys. The hair has an acid odor. 

Etiology. — Dr. Osorio thought that the nodes were 
produced by an agglomeration of epithehum in certain 
parts of the hair. Morris believes that it is a fungoid 
growth, and due to the use of a pecuhar mucilaginous 
linseed-like oil by the natives, especially by the women, 
to keep the hair smooth and shiny. Another theory 
is, that it depends upon the use of the waters of certain 
stagnant rivers, which are very mucilaginous, Heat 



ATROPHIA PILORUM PROPRIA. 139 

seems essential for its production, as the use of either 
the oil or the water fails to cause the disease in cold 
climates. 

Pathology. — The hair is found to be dark, weak, 
and flaccid. The nodes are very hard to cut, and 
when considerable force is used they break. Under 
the microscope the appearance is that of a honey-comb 
mass consisting of spore-hke bodies, deeply pigmented 
on their surface. The mass in its early stage seems to 
originate from one cell that grows by budding in every 
direction, forming radiating columns of spore -like 
bodies. As soon as the mass has grown to a certain 
size, the surface cells seem to alter in shape, become 
darker in color, and form a pseudo-epidermis. Mor- 
ris, (293). 

Diagnosis. — It is differentiated from trichorrhexis 
nodosa by the stony hardness of the nodes, by its oc- 
curring principally upon the scalp-hair, by its probable 
etiology and by the microscopical appearances it pre- 
sents. 

The third nodular disease of the hair is 

Tinea Nodosa. 

This name is selected biy Cheadle and Morris (278) 
to designate a condition of the hair which differs from 
trichorrhexis nodosa, in the presence of a parasitic 
growth resembling, though larger than, that of tinea 
tonsurans; in the marked incrustation of the hair-shaft 
by this growth; and in the absence of multiform sym- 
metrical nodosities. It also lacks the stony hardness 
of Piedra. ^ 

According to their description the hair follicles and 
the skin were unaffected, and the hairs were firmly 
fixed in their follicles. The affected hairs looked as if 
incrusted by a granular material around and external 
to the shaft. In some places splitting of the hair and 



140 DISEASES OF THE HAIR AND SCALP. 

incrustation occurred together; in other places incrust- 
ation was seen alone, the hair-shaft being intact though 
somewhat cloudy and opaque. The incrustation in- 
creases toward and reaches its maximum at the free 
extremity. With high powers the incrustation was 
seen to consist of an agglomeration of minute, spher- 
ical, light-refracting bodies of uniform size, and hav- 
ing all the characters of a vegetable parasite. The 
sporules adhered, as a rule, in masses hke fish-roe; but 
a few were found scattered about in small groups. As 
a rule none were found within the hair-shaft. When 
sphtting and fibrillar disintegration were well advanced, 
a few spore -like bodies were seen clinging to the fibrils, 
or more rarely lodged in the interstices between them. 
The spores were larger than those of tinea tonsurans. 

Morbus Paxtonii.— Paxton (295) has reported a 
case of nodose swellings of the hair of the axillae, the 
nodes depending mainly upon masses of foreign matter 
attached to the hair, but not completely surrounding it. 
Transverse sections of the affected hair through the 
node, showed nothing abnormal at the centre, but at 
the circumference the hair structure was found to be 
frayed-out and the fibres passed into the foreign mat- 
ter. The nodes had a dull, gelatinous appearance, and 
were granular in structure, with lines obscurely radiat- 
ing outwards. Most of the affected hairs were broken 
off near the point, and spht. There were no sporules. 
If a diseased hair were placed in a cultivator, it soon 
became covered with a white mold, the spores and 
mycelium of which were very numerous. 

Besides these three forms of atrophic disease of the 
hair, there have been several abnormalities of growth 
reported from time to time, mention of which must be 
made in this chapter. Thus Michelson (iO) mentions 
cases similar, in some respects, to Paxton' s case, in 
^liicb the hair of the a:dllae and genitals of profuseljr 



ATROPHIA PILORUM PROPRIA. 141 

sweating individuals, become covered with uneven 
masses of crystallized sweat products. The cortical 
substance of the hair is split up so as to give to the 
hair a feathery appearance. The masses have a yel- 
lowish color, and adhere to the cortex. This form of 
degeneration of the hair, corresponds, he says, to the 
'' Trichoptilosis " of Devergie. 

There is also a condition of the hair called ^'Phag- 
mesis, ' ' in which feathers adorn the body instead of 
hair. T. Eobinson (299) cites a case of this nature, 
which occurred in a boy who was exhibited in Bremen, 
and was reported upon in Bauerle^s Magazine for 
1831. The boy's head is said to have been covered 
with feathers in place of hair. 

Ferber (282) reports two peculiar cases of change in 
the texture of the hair. Both patients were nervous 
individuals, and their hair in a few hours would change 
from being soft and curly, to become straight and 
bristly. The change followed, in one case, nightly pol- 
lutions, and in the other any special deterioration of 
the always feeble health. After a time the hair would 
return to its usual condition. 

NoDULi Laqueati is that condition of the hair 
in which it seems to tie itself into knots. The hair 
is usually dry and curly. According to Michelson 
(40), the condition is common in trichorrhexis nodosa. 
The loop of the knot forms an excellent net to 
catch dust and fljang particles, and hence under 
the microscope, all sorts of dust elements are found 
with the hair. A case of this sort is reported by 
L. D. BuLKLEY (277), which occurred in the pubic 
hair of a man who was troubled with itching and 
sweating of the genitals. The hair looked as if in- 
vested with the nits of pediculi, but the microscope 
showed that the appearance was due to the presence 
of a double knot on each hair, composed of several 
turns. 



112 DISEASES OF THE HAIR AND SCALP. 

I have recently met with a case of undoubted tri- 
chorrhexis nodosa of the beard, in which this knotting 
of the hak occurred. The patient was of unsound 
mind, and kept constantly puUing at his beard, and to 
this habit was ascribed the knotting. Michelsox as- 
cribes the disease to improper combing, and pulling of 
the beard through the fingers. 

Note. —Since the completion of this chapter an important article 
upon the subject has appeared in Virchow's Archiv by Beh- 
REXD (275), entitled '"Ueber Knotenbildung am Haarschaft." 
According to him the trichorrhexis nodosa of Kaposi differs from 
the nodular swellings of the hair-shaft described by Anderson, 
Smith, and Lesser, in having grayish nodes, while the latter have 
dark colored ones; in fracturing through the nodes, Avhile in the 
other form, the fracture takes place through the internodular 
portion; and in the breaking up of the medullary canal at regular 
intervals in the latter group. He proposes the names of "]S^odo- 
sitas pilorum Smithii," or "Aplasia pilorum intermittens seu 
moniliformis'' for the latter group, Avhich he regards as an 
anomaly of hair formation, an aplasia, and not as an accident to 
already formed hair. Ringed hair he regards as a stage of tric- 
horrhexis nodosa, the nodes being the diseased i^ortion and the 
internodes the normal. 



OHAPTEE IX. 

HYPERTROPHIA PILORUM. 

Synonyms: — Hypertrichosis; Hirsuties; Trichauxis; 
Polytrichia; Dasyma; Dasytes; Trichosis hirsuties; 
Foils accidentels (Fr.); Superfluous hair; Hairiness. 
(Eng). 

Definition: — A growth of hair which is either ab- 
normal in amount or occurs in places where, normally, 
only lanugo hairs are present. While it is normal for 
a man to have a beard from four to six inches in length, 
it would be abnormal for him to have one reaching to 
his feet. Again, while normally the hair grows thick 
and strong upon the cheeks, chin, and upper lip of a 
man after puberty, should such a growth occur upon 
the face of a woman it would be abnormal. 

Symptoms. — Hypertrichosis may be general or par- 
tial, congenital or acquired. Of these the general form, 
hypertrichosis universalis, is very rare, while the ac- 
quired form, or hypertrichosis partialis, is the most 
frequent, and is familiar to every one in the cases of the 
unfortunate bearded women. 

Hypertrichosis universalis is generally congenital, 
and, in spite of its name, does not affect the 
whole body. Hair never develops, even in this dis- 
ease, in places in which normally no hair is found. It 
is not met with, therefore, upon the palms of the 
hands, the soles of the feet, the backs of the last pha- 
langes of the fingers and toes, the inside of the labia 
majora, the prepuce, or on the glans penis. Subjects 
of this malady are usually born covered more or less 



1^4 DISEASES OF THE HAIR AND SCALP. 

thickly with hair, which may be hght or dark in color. 
This continues growing longer, coarser, and darker till 
it reaches its full development. As a rule the long 
hair covering the body is fine, resembhng more the 
hair of the head than of the beard, as is also the case 
with the hair on the face of these persons. It follows 
a definite direction in growing, and this is away from 
certain well-defined centres. Thus on the back it 
grows on each side downward and outward from the 
spinal column; on the forehead away from the middle 
line, following the lines of the eyebrows; on the face, 
also, from a line running down the middle. With this 
excessive growth of hair there is usually combined a 
deficiency of teeth, specially marked in the upper jaw. 
MiCHELSON (353) has seen a family which was very 
hairy, in many members of which there was a defect 
of all five back teeth, the alveolar processes for the 
same being wanting. 

These homines pilosi are met with in all parts of the 
world. Thus we have records of the Kostroma family 
from Eussia, a father and son. They first attracted 
notice some twelve years ago, and were described in a 
number of European medical journals. The father 
died about four years ago in Paris, and the son was 
lately on exhibition in this countr}' . Nothing is known 
of the parentage of the father, nor have I found any 
record of the boy's mother. An excellent likeness and 
description of the father is given in the last volume of 
Ziemssen's Handhuch der speciellen Patliologie und 
TJierapie. The son is said to be sixteen years of age, 
and looks hke a well- developed boy, though somewhat 
under the average height. He appears to be muscular, 
and is active and energetic in his actions. He seems 
intelligent, and certainly showed acuteness in the 
rapidity and correctness with which he gave me change 
for a dollar bill when I bought his photograph. He 



HYPERTROPHIA PILORUM. 



145 



speaks his native language with great rapidity, and has 
picked up some German and Enghsh words. His agent 
says that he is docile, and his health is good. His head 
is covered with a luxuriant growth of fine, glossy hair 
of blonde color, some six inches long. This extends 
further down on the neck than is usual. The scalp is 
normal, white and soft. Coming forward, the hair 




The Dog-faced Boy. 

grows well down on the forehead, and then continues 
over the whole face, though on the face it is finer and 
lighter in color than on the head. The facial hair does 
not resemble in texture the usual hair of the beard, 
even where it grows in the places ordinarily occupied 
by that growth in men, but is nuich softer. Upon 
the upper hp there is a space occupying about the mid- 



liG DISEASES 01^ THE HAIR AND SCALP. 

die third, where the growth is very scanty. Under the 
eyes the hair also is absent for a space of about half an 
inch. Otherwise the whole face is covered with long 
hair, growing from the inside and outside of the 
nose and continuing all down the neck. There is 
also a luxuriant growth of hair from the inside and 
outside of the ears. Under each eye there is a 
group of three or four black hairs. The hair of the 
face is some four inches long. Upon the body the 
most remarkable growth is down the spinal column, 
where the hair stands out not unlike a horse's 
mane. The rest of the trunk and the extremities 
are completely covered with hair, but not very much 
more so than in not a few other hairy people. The 
backs of the hands present nothing remarkable. On 
the body the hair is exceedingly fine and delicate, 
and more fluffy than that on the head and face. 
There is a cast in his left eye, and he is near- 
sighted. He has only five teeth, two upper canine, 
and two lateral, and one middle lower incisor. The 
alveolar ridges show no sign of there ever having 
been any more teeth. The teeth he has are badly 
shaped and discolored. His father is said to have had 
no teeth till he was seventeen years old, and then only 
four in the lower and one in the upper jaw. The Lon- 
don Lancet in 1873, reported the boy as having four 
incisor teeth in the lower jaw, so he must have lost 
one. 

Other instances of universal hypertrichosis have 
been reported. Thus the case of Barbara Ursler is 
cited by Stricker (370) as occurring in the seventeenth 
century. This woman's whole body was covered with 
blonde, soft, curly hair, and she had a thick beard reach- 
ing to her girdle. In a book pubhshed in 1642 and en- 
titled Aldrovandi Monstrorum Historia there is an 
account of a hairy family consisting of the father aged 



HYPERTROPHIA PILORUM. 147 

forty, a son aged twenty, and two daughters aged 
eight and twelve. They came from the Canary 
Islands, and were covered with hair, excepting that 
the daughter's lips, nose, neck, breast, and hands were 
smooth. In 1851, Chowne (328) reported a case of 
universal hirsuties occurring in a Swiss woman twenty 
years of age. Her body was covered with hair except- 
ing on the breasts and chest, which were free of the 
growth. In Beigel's (11) book on The Human Hair, 
accounts of several cases of this deformity are given, 
viz.: that of Julia Pastrana, a Spanish dancer; and of 
Shewe Maon and his daughter Maphoon, in India. 
The latter 's second child was hairy hke its mother. In 
the father and daughter there was an absence of the 
canine and molar teeth. But it is useless to multiply 
examples, as the foregoing cases are sufficient. 

Of partial congenital hypertrichosis we have an im- 
mense number of examples. This condition is apt to 
be of the nature of naevus. It must be held in 
mind that the distinction between a localized hy- 
pertrichosis and a naevus is made mostly upon the 
color of the underlying skin. In the former case 
the skin is perfectly normal, while in the latter it 
is pigmented and may be otherwise altered. Thus 
we have, in the Lancet of 1869, an account of a 
Mexican woman who had a naevus pilosus extending, 
like a pair of bathing trowsers, from the umbilicus an- 
teriorly and the sixth dorsal vertebra posteriorly, to 
about half-way down the thighs, covering the but- 
tocks. Cummin (329) mentions the case of a lady who 
was noted for the beauty of her face, whose body from 
breast to knee was covered with a profusion of black, 
thick, bristly hair. Waldeyer (S3) reports the case of a 
girl nine years of age, who had a lock of hair running 
from the first to the fourth lumbar vei'tebra, and a 
smaller one from the third to the fourth cervical verte- 



148 DISEASES OF THE HAIR AIsTD SCALP. 

bra. These localized and partial cases of hypertri- 
chosis are most frequently met with in the sacral or 
lumbar region, and not infrequently are associated 
with spina bifida. 

Partial acquired hypertrichosis is more common 
than the congenital variety, and takes the form either 
of au excessive growth of hair in regions where it is 
usually found, or of the development of hair in regions 
usually hairless or only provided with downy or lanugo 
hairs. 

The following cases are instances of excessive growth 
and precocious development. Chowne (328) speaks of 
a boy eight years of age, who had the whiskers of a 
man. Beigel (321) has seen a six-year-old girl with 
pudenda Uke a twenty-year-old w^oman, both in shape 
and hair. This form is called '^Hetero-chronie of 
Hair" by Bartels (318). As cases of excessive 
growth may be cited the following: Leonard (64) 
mentions the case of a man in his neighborhood whose 
beard measured seven feet six and a half inches in 
length. Other instances of excessive length of beard 
are met with in medical Mterature, such as that of the 
carpenter at Eidam, whose beard was nine feet long, 
and w^ho was accustomed to carry it in a pocket de- 
voted to the purpose; and that of the Btirgermeister 
of Braunau whose beard reached to the ground. Wil- 
son (378) met with a lady who was five feet five in- 
ches in height, whose hair, when she walked, trailed 
three or four inches on the fioor. Many men have an 
excess of hair upon the chest and shoulders. Hair is 
generally more developed upon the forearm than upon 
the upper arm, and upon the leg than upon the thigh. 
As men grow old they are apt to have long hair grow 
from the nostrils and the ears. These are instances of 
the growth of strong hair where normally languno hairs 
alone are present. But these cases are interesting only 
as curiosities^, and as subjects of study. 



JIYt>EKTROPHlA PlLOKUM. liO 

Bearded Women.— The growth of the beard in 
womea is the form of hypertrichosis which concerns 
us most, as it is the deforrait}^ which we will be called 
upon to cure. As women grow old, especially after 
they have passed through the climacteric period of 
middle life, a slight mustache or a few straggling dark 
hairs on other parts of the face often appear. These will 




Bearded Woman. 

seldorQ annoy them much, as they are accepted as evi- 
dences of advancing years. The case is very different 
when a young woman is afflicted with a beard, and 
most of the patients who a])ply for relief from their 
facial hair are between twenty and thirty -five yeai's 
old. The hair generally begins to grow so as to be 
noticeable at about the eighteenth year of age. To 
get rid of the trouble the tweezers are fii'st resorted to, 



150 DISEASES OF THE HAIR AND SCALP. 

and this only makes matters worse. Then depilatories 
are tried which have but a passing effect, and some of 
them leave bad scars. Sometimes burning is at- 
tempted, and as a final refuge the razor is used. All 
the time the hair grows coarser and more abundant. 
Were this aU, though it would be bad enough, these 
cases would not so greatly need our aid. The deform- 
ity is only the beginning of evils. These women shun 
company, keep themselves shut up all day, their 
health deteriorates, and, constantly brooding over 
their misfortune, they are prone to become hypochon- 
driacal and melanchohc. Anyone devoted to derma- 
tological practice must have seen these nervous, sensi- 
tive women, whose health is broken and spirits de- 
pressed on account of, it may be, no very formidable 
facial hirsuties. The amount of hair presented by 
these cases varies. Perhaps the commonest growth 
is a mustache alone. In most of my cases the hair has 
grown thickest and coarsest under the chin and upon 
the front of the throat. It is rare, even in the best 
developed cases, to have much hair under the lower 
lip. Sometimes the growth is as complete, as heavy, 
and as coarse as is met within men. An excellent 
account of such a case is described by Duhring (330). 
The skin of many of my cases has been coarse, muddy, 
greasy, and studded with acne. 

From time to time cases of ti^ansitory hypertrichosis 
have been reported. This has been noticed druing the 
treatment of a fractured limb, the hair being much 
more prominent upon the part that has been kept quiet 
and warm. In some of these cases the increase is pro- 
bably more apparent than real, the hair not having 
been rubbed off by friction. Likewise, after injury 
to nerves the hair sometimes becomes hypertrophied, 
only to fall off after recovery. Continued irritation 
of a part, as by blisters, may stimulate hair -growth 



HYPERTKOPHiA PILORUM. 151 

which may or may not be transitory. The most in- 
teresting of this group of cases are those instances 
of hirsuties occurring during pregnancy, and disappear- 
ing again some months after parturition. Wilson 
reported a case of delayed appearance of menstruation 
in which hair grew upon the face. After the men- 
strual function was established, the hair ceased to 
grow and gradually fell off. 

Etiology. — The cause of hypertrichosis is very ob- 
scure in some of its forms, while in other varieties 
we can more readily discover it. In universal hirsuties 
heredity plays an important part. Such instances as 
those of the Kostroma father and son; of She we 
Maon, and his daughter and grandchild, and others 
like them, attest this fact. But hereditary tendencies 
will not explain the first appearance of these congenital 
cases. YiRCHOW (375) endeavored to account for them 
upon the theory of nervous influence, founded upon 
the fact that in the Kostroma people the lack of devel- 
opment of the teeth and jaws was in the same zone 
of nervous influence as was the over-development of 
the hair on the forehead, nose, cheeks, and ears; these 
regions all being supplied by branches of the trigem- 
inus or fifth cranial nerve. Atavism is another theory 
to account for these cases. When we remember that the 
foetus is completely covered with hair of some length 
and coarseness, though not coarse, there is good 
ground for believing that Unna's"^' theory of congenital 
hypertrichosis is right, namely: " That it is due to a 
persistence of the foetal or primitive hair; the change 
of type between the primitive and permanent hair not 
taking place." While normally the change in t3^pe 
does take place and the primitive hair of most of the 
body is replaced with lanugo hair, in some individuals 

*Ziemssen's Ilaiidbdch, Vol. XIV., p. 50. 



152 DISEASES OF THE HAIR AND SCAL?. 

for some unknown cause the primitive hair remains, 
grows stronger, and we have the homines pilosi. 

At the present time it is hardly necessary for us too 
gravely to discuss the theories of maternal impressions, 
fecundation of the human female by a hairy animal, 
and the like. 

The cause of acquired hirsuties is, in some cases, not 
far to seek. Heat and moisture will apparently in- 
crease the growth of hair, just as they favor the 
growth of vegetable Hfe. Thus the hair has grown 
luxuriantly under the stimulation of poultices, and on 
the limbs when confined in a fracture box. To these 
factors must be added an increase of the flow of blood 
to the part, which will stimulate hair-growth indepen- 
dently of heat and moisture. At least Prentiss' (134) 
case of hair growing more luxuriantly and coarser under 
the use of pilocarpin, which causes hyperaemia of the 
skin, would seem to indicate this. Hypertrichosis fol- 
lowing injury to nerves is probably dependent upon 
vaso-motor disturbances. The growth of hair upon 
exposed parts, as upon the arms and chests of laboring 
men, sailors, and the hke, is due to the local irritation 
of the sun and wind. 

Now we come to the more obscure cause of facial 
hirsuties in women. To account for this, numerous 
hypotheses have been formed. Probably the one most 
generally accepted is that it is in some way connected 
with derangement of the uterus and appendages. 
Because in some bearded women there has been some 
evident derangement of the sexual organs, it has been 
affirmed that some similar derangement is present in 
aU, just as many of the laity believe that the too free 
use of alcohol is the cause of rosacea. In the cases I 
have met with, the majority were as free from uterine 
trouble as the rest of their sex. While it is true that 
some of these women are of mascuhne build, and have 



HYPERTROPHIA PILORUM. 1.j3 

a masculine voice, most of them do not exhibit these 
characteristics. The heaviest bearded of my female 
patients was the mother of three children, and this 
experience is not unique. In some cases, however, 
there does seem to be some relation between the repro- 
ductive organs and the growth of the beard. Several 
instances illustrative of this have been given above. 
Eecently, I have met with a case of a woman with a 
dark but not very heavy beard, which began to grow 
about one month before the birth of her fourth child. 
The appearance of hair on the face of women who 
have ceased to menstruate would suggest such re- 
lationship. It is a common idea with women who 
have a good deal of hair on the face, that they have 
brought it on themselves by their endeavors at remov- 
ing a very shght, hardly perceptible growth. This is 
an error. Though undoubtedly shaving or cutting the 
beard may somewhat increase its coarseness, and to a 
certain extent stimulate its growth, still it cannot make 
new hairs grow. It is exceedingly likely that even if 
these women left the hair entirely alone it would in 
time become of itself coarse and dark, though it would 
be more silky. 

The question of the inheritance by the daughter of 
the physical character of the father or male ancestors 
is worth investigating. By this I mean, whether she 
resembles the father in her general build more than 
the mother. 

We may sum up the evidence on the etiology of fa- 
cial hirsuties in this way: While at times there ap- 
pears to be a relation between the uterine, or, more 
properly, the menstrual function, and the growth of 
hair on the face, shown by a decrease or deficiency of 
the first, and an increase of the second, still in the ma- 
jority of cases no such relation is discoverable, and it 
must be viewed as a deformity or freak of nature. 



151 DISEASES OF THE HAIR AXD SCALP. 

An interesting study of the relation between hirsnties 
in women and insanity was made by Hamilton (339). 
He regards hair growth on the face in women as the 
inevitable result of the overactive and continuous ex- 
ercise of the uterine and ovarian functions. He be- 
Meves it to be of neuropathic origin, connected with 
disorders of the fifth cranial nerve; and when it occurs 
upon the face of an insane person it is indicative of an 
unfavorable form of insanity, especially if the subject 
has not reached middle life. Shaw (361) speaks of the 
hau of chronic lunatics changing from fine to coarse 
and increasing in quantity, specially during or after vio- 
lent outbreaks of insanity, and ascribes it to the effect 
of long-continued increase of temjDerature of the scalp, 
leading to a greater activity of the hair-bulbs. 

Treatment. — The treatment of hypertrichosis is sim- 
ple and efficacious, though laborious and tedious. For 
general hypertrichosis we can practically do nothing. 
This, not because we cannot destroy the hair so that it 
wiU not grow again, but because of the great amount 
of time it would take to destroy it. Happily, a super- 
fluity of hair on the body does not incommode the 
bearer of it, nor, in most cases, do liim any damage. 
One case, however, is upon record where the conse- 
quences of too much hair resulted in serious damage. 
It is that of a woman in old times whose face was very 
beautiful, and who made an advantageous marriage. 
But the husband was disgusted to find her body cov- 
ered from breast to thighs with a profuse growth of 
stiff coarse hair, and upon the strength of this he was 
divorced from her on the next day. 

The only form of hirsnties which urgently calls for 
rehef is that occurring upon the face of women. Until 
recently there was no cure for this, but in 1879 Michel 
(380), of St. Louis, devised a method for removing the 
hairs in trichiasis by means of electrolysis^ which was 



HYPERTROPHIA PILORUM. 155 

taken up bj Hardaway (341), of the same city, for 
the remoYal of superfluous hau\ Piffard (29) had al- 
ready in 1876 spoken of the removal of superfluous hair 
from hairy naevi by this method. Since then the art 
has been practised by a number of physicians, notably 
by Dr. George Henry Fox (336) of New York. The 
question is often asked: '^Is the removal, by this 
method, permanent?" This question may be an- 
swered, '^It is, without a shadow of a doubt." The 
object being to destroy the papilla, and that being very 
smaU and often placed at an unexpected angle to the 
surface of the skin, it is not possible always to accom- 
plish this at the first attempt. The amount of success 
on going over the face the first time will vary with the 
operator, and, according to his skill, there will be a re- 
turn of from twenty to fifty per cent, of the hairs re- 
moved. It will be necessary, therefore, to go over the 
face a second or a third time, but then there will be no 
return. At times, after the dai^k coarse hairs have 
been removed there will be found a number of finer 
and lighter hairs. This appearance is due partly to 
the uncovering of these hairs, and, partly it may be, to 
lanugo hairs becoming stronger under the stimulation 
of the operation. In most cases, with proper care and 
the use of a fine needle, the amount of scarring will be 
very slight, amounting to nothing more than fine 
punctate cicatricial spots. In some peculiarly irritable 
skins it is very difficult to prevent the formation of 
plainly visible scars. If the proper conditions are not 
observed, the operator must expect to produce a good 
deal of disfigurement. 

The amount of pain experienced by the patient will 
vary greatly. Some women will complain bitteily of 
a current of half the strength that other women will 
bear with ease. Certain parts of the face are far more 
sensitive than others. The most sensitive points, ac- 



156 DISEASES OF THE HAIR AXD SCALP. 

cording to my experience, are over the ridge of the 
lower jaw on each side of the chin, and about the up- 
per hp. On the whole, the pain does not amount to 
much, and if it does, I have found that it may be 
greatly lessened by rubbing the oleate of cocaine into 
the skin for some five or ten minutes before beginning 
the operation. After a time the skin seems to become 
tolerant of the action of the current and the patient no 
longer complains. Hyperj^igmentation may be pro- 
duced by the operation. This is a very rare compli- 
cation, and is only mentioned by way of warning. I 
have seen it in only one case, a hypochondriacal 
woman, and here, instead of the redness which is al- 
ways produced about the point of puncture fading 
away in a few days, it gave ^^lace to a dark-brown 
stain which remained for a number of months. 

The instrmnents needed for the operation are a good 
twenty cell zinc-carbon (galvanic) battery, a sponge 
electrode, a proper needle-holder, a fine needle, a pair 
of epilating forceps, and, if the operator's eyes are not 
good, a lens of low power. Any sponge electrode will 
answer. There are various patterns of needle-holders, 
any one of which may be used. I prefer one which is 
not longer than three or three and a fourth inches, 
with a diameter of about three-sixteenths of an inch. 
It should be long enough to be held with ease, and not 
too long to be readily manipulated. If the woman has 
a large bust, a high chest, and a short neck, a short 
holder will be found a great convenience when work- 
ing under the chin. There is a form of needle-holder 
in the market furnished with an attachment for cut- 
ting off the current and letting it flow again after the 
needle is in place in the follicle. This I camiot recom- 
mend, as it causes a very uncomfortable shock to the 
patient, much more than that experienced in using the 
method detailed below. The most essential instru- 



HYPERTROPHIA PILORUM. 157 

ment is the needle, and for the best success this must 
be carefully chosen. At first the finest cambric needle 
was used, and it did fairly well. Hardaway, (342) 
recommends a needle made of iridium and platinum, 
claiming that it will follow the direction of the hair 
follicle and hit the papilla more surely than the steel 
needle will. I have used these needles, but have not 
found them so satisfactory as the steel "broaches," 
which are fine-pointed steel needles used by jeweller's 
and obtained at any jeweller's supply store. They 
come in many grades of fineness. It is advisable to 
have two grades. No. 5 for the coarser hair, No. 7 for 
the finer, and for the lip. Care should be exercised in 
selecting them, as they are so fine that their points are 
sometimes broken while in the packages . A lens is gen - 
erally not needed. Piffard (359) has invented a needle- 
holder with a lens attachment, which he has found use- 
ful. Good eyesight and a steady hand are the essentials 
to be supplied by the operator. If he has not these, he 
had best not attempt the operation. A good light is ne- 
cessary for the operation, that is, one that is steady and 
not glaring. A cloudy day with changing light is try- 
ing to the eyes. I have been able to work with much 
comfort on dull days, even under the chin, by spread- 
ing a white napkin over the patient's throat and upper 
chest. An operating or reclining chair is a comfort, 
and the patient should be so placed that the part to be 
operated on is on a level v^th the operator's eye. 

The operation is done in the following manner: The 
patient, being in position, is to be given the sponge elec- 
trode attached to the positive pole of the battery, and 
told to hold it in one hand. The hair to be extract- 
ed is to be seized with the forceps, and put slightly on 
the stretch in the direction in which it naturally grows. 
The needle-holder is attached to the negative pole, and 
hel4 like a pen holder. Ttie needle is then inserted paral- 



153 DISEASES OF THE HAIR AND SCALP. 

lei with the hair and into tne fuihcle. One soon learns to 
know whether the follicle is entered or not by the sense 
of touch. When the f olhcle is entered the needle ghdes 
along smoothly; when it is not entered a sense of re- 
sistance is communicated to the fingers as the skin is 
punctured. The depth to which the needle is to be 
thrust will vary with the case. Eoughly speaking, it 
is from one-sixteenth to three- sixteenths of an inch. 
The needle being inserted, the patient is told to place 
the palm of the disengaged hand over the sponge elec- 
trode. Watching the effect on the skin, a slight hy- 
peraemia will be noticed about the point of insertion of 
the needle, which almost instantly gives place to a 
blanching of the tissues. In a few seconds there will 
be frothing about the needle, and in from half a min- 
ute to a minute, the hair will come away upon the 
very slightest traction. 

Such is the operation. Care must be taken to use 
the negative pole, for otherwise, instead of an electro- 
lytic action, a charring of the tissues will result, and per- 
manent blackish spots will be left in the skin. The 
hair must not be pulled on with any force, for the ease 
with which it leaves the follicle is a guarantee of the 
completeness of the operation. The hairs must not be 
extracted in close proximity, because the inflammatory 
action thus set up will lead to more or less ulceration 
and subsequent prominent scars. At first, at least 
some three-sixteenths of an inch should be left be- 
tween the hairs; later, when the susceptibility of the 
skin is known, they may be taken out nearer to each 
other. It is best only to extract the coarser hair and 
to leave the lanugo hairs alone. The strength of the 
current to be used wiU depend upon the quality of the 
patient's skin and the recentness of the filling of the 
battery. Eight ceUs are the fewest I have used, and 
fifteen the greatest number: that is, a current of from 
ono halt' to quq and a Jbialf roiUiamperes, 



HYPERTROPHIA PILORUM. 159 

The immediate effect of the operation is the produc- 
tion of a number of wheals which are evanescent. On 
the next day only red points are seen, and in a few 
days no traces of the operation are visible, or else min- 
ute cicatricial points, when the skin is examined with 
the greatest care. The finer the needle is, the less the 
reaction will be. The patient should be directed to 
bathe the face in hot water after the operation, 
and to anoint it with cold cream. If these direc- 
tions are carefully carried out, and the requisite 
skill in the introduction of the needle is acquired 
by practice, an absolute cure will be the result. 

While the just detailed operation is the only one 
which is at all certain of success, various other means 
have been tried to destroy superfluous hair, and, for 
completeness, must be given in this place. Depilatories 
are of very ancient date, and there are many vaunted 
ones now in the market. Many of my patients have 
used many kinds. That they have come to be operated 
on by electrolysis tells the tale of the failure of depila- 
tories. Still, they are useful in some conditions. When 
the patient's hair-growth is very fine they may be ad- 
vised, as fine hair is not so favorable for operation as 
is coarse hair. When the hair-growth is partly fine 
and partly coarse it is a good plan to remove the whole 
by a depilatory, and thus lighten our work, as the 
coarse hairs will naturally appear first in growing, and 
then can be removed before the fine hair obscures them. 
Depilatories act only on the hair above the surface 
and not on the roots. Anderson recommends one 
composed as follows: 



Sulphuret of barium. 
Oxide of zinc, 


3iss=:6. 

3VJ=.1>1:. 


Carmine, . . , 


F-J=^^^' 



160 DISEASES OF THE HAIR AND SCALP. 

Some of this powder is to be mixed with enough 
water to make a paste, apphed to the part and washed 
off in three minutes. Duhring (10) gives the following 
formula: 

Sodii sulphid, . . . . 3ij=8. 
Cretae preparat, . ; . . 3vj=24. 
M. 

This is to be made into a paste with water and ap- 
phed as a thin coating, and left on for ten or fifteen 
minutes. As soon as it causes heat of the skin, it is to 
be washed off, and the part is to be anointed with a 
bland ointment. 

Leonard (64) tells us that in Eastern harems, where 
it is the fashion to destroy the axiUary and pubic hair, 
they use a composition called " rusma " made of 

Arsenici tersulphuret, . . 3 ss=2. 

Calcis, |ss=16. 

Farinae tritici, .... 3ij=2.5. 
Aquae ferv. qs. ut. ft. pasta. 
M. 

This is applied with a wooden spatula, to the thick- 
ness of a knife blade, and left on for from five to ten 
minutes, or until it begins to sting, when it is scraped 
off with a blunt-edged knife, and the skin washed with 
warm water and dusted with rice or starch powder. 

Neumann (27) gives an extended hst of depilatories m 
his work on the skin. All of them require careful 
watching, as it is possible that their action may go too 
far. 

Nothing need be said about cutting the hair, shav- 
ing it, and puUing it out by tweezers. The most 
ancient method of getting rid of hair is by fire — burn- 
ing it off. 

C. Heitzman (344), in 1881, reported the results of a 
number of experiments with hypodermic injections^ th3 



HYPERTtlOPHIA I>ILORUM. 161 

hair being extracted and then the needle introduced 
and the injection made. He first tried the tincture of 
iodine, one part in ten, and extracted fifty hairs. 
More than one half returned in three months. He 
then used equal parts of carbonate of potash and water. 
Nearly all returned. Then caustic potash, one to six 
or four, was injected. Twenty-four hairs were ex- 
tracted from his own arm and in six months only six 
retruned. He thinks that in the strength of one to 
four with a fresh solution it is capable of destroying 
hair under symptoms of suppuration. The needle 
should be run obliquely under the skin and given a 
rotatory motion. Many other attempts to destroy hair 
by means of introducing needles dipped in various sub- 
stances into the follicle have been made with indiffer- 
ent success. It would seem that the medicament 
would be rubbed off against the walls of the upper part 
of the follicle before it could reach the papilla, and that 
any good effected would be due to exciting a suppura- 
tive action at or near the surface of the skin. 

BuLKLEY (324), in 1878, reported several successful 
cases treated by means of a three-cornered surgical or 
glover's needle, which was passed into the follicle and 
rotated while in the region of the papilla so as to break 
up its substance. The hair is to be seized with the 
epilating forceps, put slightly on the stretch, and the 
point of the needle placed at the mouth of the follicle. 
The needle is to be slowly pressed in and the hair puUed 
out when the needle will pass into the follicle. Gener- 
ally no bleeding occurs, and the operation is not very 
painful and no scarring i^esults. This is a good method 
of treatment where there are only a few hairs to be re- 
moved and a galvanic battery is not at hand. 
11 



OHAPTEE X. 

TRICHIASIS AND DISTICHIASIS. 

These diseases belong to the domain of the opthalmic 
surgeon, rather than to that of the dermatologist, but 
they are usually included in systematic treatises upon 
the skin, under the section upon Hypertrichosis. They 
occur not infrequently: the last report, (1886,) of the 
Manhattan Eye and Ear Hospital showing 20 cases in 
458 cases of diseases of the eyelids. 

Trichiasis is a congenital or acquired misplace- 
ment of the cilia, so that they are directed backward 
toward, and scratch upon, the globe of the eye; com- 
bined with a growth of lanugo hairs with the same in- 
clination backwards. This condition is usually ac- 
quired, though there may be some original irregularity 
of the cilia. These are not only misplaced so as to 
point backward, but are often tv\risted or distorted. 
As a rule both the upper and lower lid are affected; and 
both eyes may be involved in the disease. The lanugo 
hairs that are met with develop after the distortion of 
the true cilia has existed for a greater or less length of 
time. They grow from every portion of the tarsal 
margin, and even from the mucous membrane of the 
lids. 

This disease is dependent upon some long-continued 
inflammatory disease of the eyelids, which causes a dis- 
tortion of the lid and interference with the direction 
and nutrition of the hair-follicles. It therefore very 
commonly follows upon granular and purulent opthal- 
niia. 



^^RICHiASIS AND DISTICHIASIS. 16,^ 

DisticTiiasis is a congenital or acquired condition in 
which the ciha grow in two distinct rows, the inner 
row being directed inwards so as to impinge upon the 
cornea. It differs from trichiasis in an entire absence 
of lanugo hairs, the supernumerary hairs being nor- 
mal cilia. Sometimes the inner row cannot be seen 
until the lid is everted. The condition may be partial 
or complete, usually the former. According to Michel 
(380) generally the outer third of the upper lid is affect- 
ed alone, the deformity is symmetrical and bilateral, and 
of embryonic origin. The second row of cilia springs 
from the flattened tarsal margin near its posterior 
edge. Where this arrangement of the cilia is not con- 
genital, it is dependent upon the same causes as trich- 
iasis. Both diseases cause irritation of the cornea, 
opacity of the same, panus, and ulceration, matters 
which do not concern us here. 

The treatment is palliative, as by epilation; or rad- 
ical, by operation. Until recent times the opthalmic 
surgeon has made a radical cure by cutting out either 
a piece of the lid so as to shorten it and somewhat 
evert it, or by excising a part of the tarsal cartilage 
with the offending hairs. For these matters, books on 
the diseases of the eye are to be consulted. To Michel 
(380), of St. Louis, is due the credit of first destroying 
the supernumerary and distorted hairs by means of 
electrolysis. The operation is the same as is given in 
the preceding chapter. Michel states his preference 
for a No. 8 cambric needle, because its action is not so 
limited as is that of a finer one. 



CHAPTEE XL 

SYCOSIS. 

Derivation — Gr. ^6x^(7:?, a Fig. 

Synonyms. — Sycosis non parasitica; Sycosis menti; 
Sycosis barbae (Celsus); mentagra (Plenck); acne men- 
tagra; folliculitis barbae (Kobner); folliculitis pilorum; 
herpes pustulosus mentagra (Alibert); lichen menti; 
acne sycosis (Mcwrris); Fr: Sycosis non parasitaire, 
dartre pustuleuse mentagra, adenotrichie (Hardy); Ger: 
Bartfinne, Bartflechte, Fikosis; Eng: Barber's itch. 

Definition. — A chronic follicular and peri- follicular 
inflammation of the long hairs, chiefly affecting the 
bearded portions of the face; characterized by an 
eruption of papules, pustules, and tubercles perforated 
by hairs; by the formation of infiltrated patches; and 
by a greater or less amount of crusting. 

Symptoms. — It is only of comparatively recent years 
that this disease has been recognized as a separate en- 
tity, and it is still regarded by some authorities as merely 
a form of eczema. But the experience of the major- 
ity of dermatologists has taught them, that the disease 
is quite independent of either eczema or trichophytosis 
barbae. The disease begins by the formation of a num- 
ber of red inflammatory papules and tubercles, which 
are more or less conical, usually raised above the sur- 
face of the skin and always perforated by hairs. Their 
appearance is preceded and accompanied by disagree- 
able local sensations, such as pricking, burning, and 
smarting, and at times by a feeling of tension in the 
part, on account of swelling of the skin. In acute 



MYCOSIS. 



165 



<5ases there is considerable redness of the skin between 
the papules, and the inflammation may be so intense 
as to give rise to enlargement of the neighboring lym- 
phatic glands. The papules and tubercles vary in size, 
from that of a millet seed to that of a pea, and are iso- 
lated or grouped, not every hair-follicle in a diseased 
part being affected by the peri-f olHcular inflammation. 




Only in very severe outbreaks or in acute exacerba- 
tions do the papules and tubercles tend to run together 
and form infiltrated patches. 

The papules and tubercles soon change into pustules, 
which preserve the same characteristics of grouping 
and are likewise always pierced by hairs. These pus- 
tules, conical in shape and perforated by hairs, are 
patliognomoiiic of the disease. In old cases they are 
met with in the infiltrated patches, arising apparently 



166 MSEASES OF THE HAIR AND SCALP. 

without the preceding appearance of papules and tu- 
bercles. The pustules show no tendency to rupture, but 
the pus accumulates below, wells up alongside of the 
hair, apj^ears upon the surface of the skin and dries 
into thin crusts. The amount of crusting is never very 
great, far less than in eczema of the beard, and is ap- 
preciable mainly when the beard is growing. If the 
inflammation is very intense, we may meet with small 
cutaneous abscesses here and there, instead of pustules. 
According to A. R. Eobixsox (33) the amount of pus pro- 
duction varies with the individual attacked, being more 
rapid and abundant in the robust than in the scrofu- 
lous; in acute than in chronic cases. 

The hair, if of any length, is early affected in appear- 
ance, becoming lustreless. It is at first firmly seated 
in its follicles, and when pulled upon gives rise to pain, 
and if extracted its root-sheath wiU appear as a clear 
glassy cylinder. Later, as pus forms more abundantly 
in the peri- follicular tissues, and the f oUicles themselves 
are involved in the process, the hair becomes loosened 
and easily extracted, when its root-sheath wall be found 
swollen with pus. If the pus production is excessive, 
the hairs vnR faU of themselves or upon the slightest 
traction. When this occurs the hair papilla may be so 
damaged that no new hairs wiU form. In chronic 
cases the beard is markedly thimied, though perma- 
nent loss of hair is the exception. 

The disease may attack any part of the bearded face, 
and may be met with in other hairy regions, as the 
neck, the eyebrows, scalp, axiUa, and pubes. But 
the beard is by far most often the site of the disease, 
the other situations being affected in the order in 
which they are named. Occurring in the beard, it may 
be limited to a single region and show no tendency to 
spread. Thus, it is met with very frequently upon the 
upper hp alone, or at times only upon the chin. It 



BYCOSIS. 1C7 

may attack the whole bearded face in an acute out- 
break, or it may involve it by extension from a limited 
area during a number of successive outbreaks. In 
chronic cases it is usually symmetrical. The course of 
the disease is chronic and made up of a number of 
acute exacerbations. If left to itself it may produce 
a good deal of deformity, the tubercles and pustules 
breaking down, ulcerating, and leaving cicatricial tis- 
sue and more or less baldness. 

A typical case of sycosis presents the following ap- 
pearances. Upon a single region, two or more regions, 
or upon the whole bearded portion of the face, there 
wiU appear a number of isolated or grouped papules, 
tubercles or pustules pierced by hairs. The skin about 
the lesions is reddened and swollen, it may be indur- 
ated, and there is a slight amount of crusting. There is 
no tendency for the disease to spread to non-hairy parts, 
but very commonly the eyebrows will be similarly af- 
fected, and a blepharitis will be present. In some chronic 
cases there wiU be much loss of hair and some scarring. 

When the case is watched for a time, marked exacer- 
bations will arise, often without apparent cause, last for 
a few days, and then the disease will sink into a sub- 
acute condition. 

When the disease affects the vibrissse of the nose, by 
extension from the upper lip, the Schneiderian mem- 
brane becomes swollen and exquisitely sensitive. 

Etiology. — The etiology of the disease is not settled. 
Statistical tables show that it occurs about three times 
in every thousand cases of skin diseases. It probably 
occurs more often than this, as some cases recover 
rapidly under domestic treatment or even when left 
alone. It is non-contagious. > It is seen in men al- 
most exclusively, as we might expect, and attacks them 
most frequently between the ages of twenty-five and 
fifty. Both the well nourished and the poorly nour- 



168 DISEASES OF fHl HAIR AND SCAL?. 

ished, the rich and the poor, suffer from it. I have 
seen it very frequently in tailors, and in them it 
has proved very obstinate. Eczema is often a fore- 
runner of sycosis, the one process passing over into the 
other. A nasal catarrh is the cause of the majority of 
cases occurring on the upper hp. Shaving with a dull 
razor against a stiff beard is sometimes an exciting 
cause, though those who do not shave are by no means 
exempt from the disease. An irritant applied to the 
skin may excite it, such as exposure to intense heat, 
the dust of a workshop, cosmetics and the hke. Ex- 
posure to inclement weather is regarded by Wilson (38) 
as the principal cause. One of the worst cases I have 
ever met with was directly traceable to a poultice ap- 
phed to the face for the relief of a neuralgia. 

Given a hyperaemic or irritable condition of the skin 
of the face arising from any internal or external cause, 
the hairs, especially if they are coarse, may excite the 
disease, acting as irritants when touched or moved. 
Hebra (39i) thinks that some cases may be due to an ab- 
normality in the growth of new hairs. Wertheim as- 
cribed the inflammation to irritation of the hair-foUi- 
cles by hairs whose diameter was relatively too large 
for their foUicles. 

Pathology. — A. E. Eobinsox (400) who has made an 
exhaustive study of the pathological anatomy of this 
disease, teaches us that it is " primarily a peri-foUicular 
inflammation of the skin. The flrst changes which 
take place occur around the follicle in the peri-folhcu- 
lar region, and are those which are usually observed in 
vascular connective-tissue inflammations. The trans- 
uded serum penetrates the hair-follicle, and as the in- 
flammation proceeds and the pus and serum increase 
in quantity, the follicle becomes more and more affected. 
Its sheaths become softened and more or less destroyed, 
and a portion of the pus may enter the foUicle through 



SYCOSIS. 169 

the ruptured sheaths. The cells of the external root- 
sheath become swollen and soon begin to break down; 
similar changes occur in the cells of the hair-root: they 
swell, the protoplasm becomes more granular in ap- 
pearance, and there is evidence of commencing destruc- 
tion. After the rupture of the follicle- sheaths, or even 
before, the cells of the hair-root and of the root- sheaths 
rapidly become broken up and changed by the trans- 
uded serum entering the follicle. If pus corpuscles 
have also entered the follicle, the hair-root is infiltrated 
with a sero-purulent matter; it does not in every case 
enter it in large amount. In the pustular stage the 
principal changes take place within the follicle; the 
hair-root and its sheaths are broken down and separated 
from the foUicle sheaths, so that the hair Hes loosely 
within the follicle. 

"As the inflammation progresses, the connective- 
tissue around the foUicle becomes crowded with pus 
cells, as far as the surface of the skin. If the hair is 
allowed to remain within the follicle until expeUed by 
the accumulating pus, the root-sheaths and soft parts 
of the hair are destroyed, and only the hard part re- 
mains. The follicle-sheath, and the peri -follicular tis- 
sue are more or less destroyed, and the Malpighian layer 
becomes ruptured at the neck of the follicle. The pus 
reaches the surface by breaking through the epidermis 
near the hair; some passes to the surface between the 
hair-shaft and the follicle -sheath. The cells from 
which the hair grows seem to resist the inflammatory 
process more than the other cells of the bulb. When 
permanent alopecia results, both the follicle- sheaths and 
the base of the foUicle are completely destroyed. If 
eczema is present the root-sheaths and follicle-sheaths 
are acted upon in their entire length at the same time. 

" The sebaceous glands may also become affected, 
though not at so early a stage of the disease as the f uiv 



iro 



DISEASES OF THE HAIR AND SCALP. 



dus of the hair, and the whole gland may be destroyed 
by a process of molecular retrograde degeneration. 
The sweat glands generally escape, but the epithehal 
cells may become detached or the glands destroyed." 

Diagnosis. — The distinguishing characteristic of sy- 
cosis is the presence of pustules pierced by hairs. It 
must be diagnosed from trichophytosis barbae, eczema 
barbae, the smaU pustular syphiloderm, acne, and lupus. 

Differential diagnosis from trichophytosis barbae. 



Trichophytosis harbce, 
Begins as a small scalj^ spot, 
a superficial ring-worm, and 
gradually involves the deeper 
parts of the hair. 

Has its favorite seat upon the 
cliin and the sab -maxillary re- 
g'ion ; rarely attacks the upper 
lip. Often asymmetrical. 

The eruption consists of tuber- 
cles and nodules which tend to 
group and are studded with a 
number of hairs. The inter- 
nodular portions of the skin of- 
ten remain unaffected. 



Is a deep inflammatory pro- 
cess as soon as the hairs become 
affected. 

Hair is diseased primarily, and 
is twisted, split and broken. 

May readily be removed by 
slight traction and without pain. 
Its root is often dry. 

Subjective symptoms slight, 
may be only slight pruritus. 



Patches of ringworm often 
present on other parts of the 
body, and sometimes the dis- 
ease extends upon the neck or 
face. 

Hairs and scales loaded with 
the tricophyton fungus. 

Is a progressive disease, and 
■^vhen cured not liable to relapse. 



Sycosis. 

Begins suddenly with an out- 
break of papules which soon be- 
come pustules, each of which at 
the start involves a hair. 

Its favorite seat is the upper 
lip, and sometimes it alone is in- 
volved. Involves the hairy por- 
tions of the face more generally 
and often symmetrically. 

The eruption consists of pa- 
pules and pustules, eacli of 
which is pierced by a single 
hair, and they show no disposi- 
tion to group. The intervening 
skin is generally reddened, and 
maj^ be diffusely infiltrated ; and 
abcesses may form. 

Is a more superficial inflam- 
mation. 

Hair diseased secondarily and 
comes away at first with difH- 
culty, causing much pain. Later 
is easily removed and its root is 
swollen with pus. 

Subjective symptoms of prick- 
ing, burning, and tension of the 
part. These are often intense 
and attended with swelhng of 
the face. 

Limited in most cases to hairy 
parts of the face. No tendency 
to extend on non-hairy parts of 
face or neck. 

No fungus present. 

The course of the disease made 
up of a number of acute out- 
breaks, taable to relapse, 



SYCOSIS. 171 

The differential diagnosis from eczema of the beard 
cannot be made with so much certitude, and often we 
must remain for a while in doubt as to the true nature 
of the case. At times the sycosis is a legacy left by a 
preceding eczema, and we may meet with a case in 
the transition stage when a sure diagnosis would, 
manifestly, be impossible. A typical case of pustular 
eczema is attended by a far greater amount of crust- 
ing than is sycosis, and the crust is of a more greenish 
or blackish color. Upon removing the crust in eczema 
a moist and oozing surface will be exposed, while in 
sycosis we wiU do no more than remove the tops from 
a number of pustules. In eczema the pustules break 
down more readily than in sycosis, and they are not 
so accurately located about the hairs. In eczema the 
whole surface of the skin is involved and the process 
tends to extend upon non-hairy parts of the face. While 
exceptionally eczema is confined to the hairy portions 
of the face this is always so in sycosis. The duration 
of the disease will at times help us to a diagnosis, sy- 
cosis being far more chronic than is eczema. 

In syphilis when the beard is involved we will find 
pustules upon other portions of the body, and the his- 
tory will help us to a correct conclusion. The pustules 
or papules of syphilis are grouped in circles or segments 
of circles of peculiar color, and their development is 
painless and comparatively slow. Pustular syphilis 
causes permanent baldness, which is rarely the case in 
sycosis. 

Acne is scattered about the whole face, is usually 
met with in young persons, comedones are present and 
its papules, pustules, or tubercles have no definite re- 
lation to the hair. 

The course and history of lupus are so different 
from that of sycosis, that it is hardly possible for 
them to be confused. In lupus vulgaris w(^ ]^.;n'o 



172 DISEASES OF THE HAIR AKD SCALP. 

the characteristic brown tubercles which do not 
contain pus, are not confined to the hairy portions of 
the face, generally begin in early hfe, and tend to ul- 
cerate or to be absorbed and leave behind cicatrices. 

Treatment. — The treatment of sycosis is both gene- 
ral and local. While many cases will yield to local 
treatment alone, there are quite as many, if not more, 
which require general treatment. The surroundings 
of the patient must be inquired into, and also his mode 
of hfe. He should be urged to take exercise in the 
dayhght; a powerful means for good if the case hap- 
pen to fall upon one constantly employed in badly ven- 
tilated rooms, such as tailors and the like. He should 
be advised against exposing himself to dust and wind, 
and even against smoking, especially in the wind where 
the smoke blows against the face. The proper regula- 
tion of the diet is important. Many cases will improve 
if we stop their tea, coffee, hot drinks of all sorts, ale, 
beer, and spirits. If the digestive process seem at all 
embarrassed, it is well to put the patient on a hght 
diet for morning and evening, and dnect him to take 
his principal meal at noon, eating meat only at that 
time. Anything that is known to him to be indigesti- 
ble must of course be prohibited. In a word the diet 
and hygiene of the patient should be regulated. 

What medicines we should administer wiU depend 
upon the stage of the disease. In the acute stage, when 
there is much svv^elLing and inflammation, a good dose 
of blue piU, calomel, or some other active cathartic is 
to be ordered, to be followed by an alkahne diuretic. 
When pustulation is active the sulphide of calcium or 
calx sulphm^ata wiU do good. Piff ard (399) recommends 
this very highly, giving one-tenth of a grain two or three 
times a day. Care must be exercised that our patient 
obtain the drug fresh. I have found the exhibition of 
the drug in the form of the tablet triturate by far th§ 



SYCOSIS. 173 

most active way. Small doses of calomel as one-tenth 
of a grain three times a day for two or three days at a 
time, are useful in relieving the congestion of the skin. 
In chronic cases, iron, cod-liver oil, and other tonics are 
indicated if there is a state of debility. Arsenic is ad- 
vised in very obstinate cases. If indigestion is present 
we must address our remedies to its relief before we 
give calcium, arsenic, or other remedy for the disease 
proper. 

The local treatment is more important than the gen- 
eral, and is required in every case. It must vary with 
the condition found, whether it be acute or sub -acute. 
When the disease attacks the upper lip the nose must 
be examined for evidences of catarrh^ and that condi- 
tion treated if found. I have had, at times, good re- 
sults from the subnitrate of bismuth or powdered cu- 
bebs, used as a snuff in this condition, but it is best 
for each physician to use for this, that which experi- 
ence has taught him to be most useful. 

In the management of an acute case of sycosis sooth- 
ing remedies are needed. Hot water should be sopped 
on the part for some five or ten minutes once or twice 
a day, and this should be followed, if the beard is grow^- 
ing, by the use of a simple oil such as olive oil or sweet 
almond oil, or if the face is shaved the zinc oxide oint- 
ment or cold cream may be used; or better stiU, Las- 
sar's paste, as foUows; 

Amyli, 

Zinci oxidi. aa . . . .3 ij — 8. 
Vasehne, ad . . . . § j —32 
■ M. 

Powdering the part with corn starch, or bismuth and 
talc, after smearing on a little vaseline, will at times 
give ease and comfort. If the i^rocess is attended 
by a good deal of ced^mc\, O-ud the inflammatory 



174 DISEASES OF THE HAIR AND SCALP. 

symptoms are severe, warm poultices will relieve the 
disagreeable sensations of the patient and reduce the 
inflammation. In some cases cold starch poultices wiU 
be better borne. Devergie (387) recommends steam- 
ing the inflamed parts every second day, and covering 
the affected parts constantly Avith cold or almost cold 
thin flaxseed poultices. Even in the early stage, if the 
inflammatory symptoms are not very intense, a mild 
white precipitate ointment will sometimes check the 
disease. Duhring (10) recommends bathing the face 
with " black wash " foUowed by zinc oxide ointment, 
with a drachm of alcohol or half a drachm of camphor 
to the ounce, spread on cloths and bound on; and 
speaks weU of the oxide of zinc ointment with fifteen 
to thirty grains of calomel to the ounce. When the 
disease has reached the pustular stage, and there is 
more or less crusting, the crusts are to be removed by 
the free use of ohve oil, or oil of sweet almonds, letting 
it soak in thoroughly over night and washing the part 
with soap and warm water the next morning. If the 
crusts are thick, it is a good plan to tie up the bearded 
face in a towel after anointing it with oil. A poultice 
may be used for the purpose of removing the crusts. 
After the crusts are gotten rid of, puU the hairs out of 
the pustules, and insist upon the patient shaving him- 
self every second day. At first he may rebel against 
the use of the razor, but if plenty of warm water and 
soap is used, and a good lather formed, the shaving 
will not be very painful, and it is only the first shave 
that is painful. Epilation of the hair from aU the pus- 
tules and papules is to be continued until they cease to 
form. Shaving is to be continued until some months 
after the skin is apparently weU. It is possible to cure 
a case without shaving, but the cure will be more difii- 
cult to effect. The patient must be made to under 
^tand that epilation is necessary, both for the cyr^ of 



SYCOSIS. 175 

the affection and the salvation of the hair. After epi- 
lating the oxide of zinc ointment, Lassar's paste, or 
diachylon ointment is to be used. Sulphur in the form 
of an ointment, half a drachm to a drachm to the ounce, 
or in powder, will sometimes do good, but often will 
prove too irritating. Tilbury Fox (390) recommends 
the use of the following ointment after shaving: 

Zinc oxide, 

Zinc carbonate aa . . .3 j — 4. 

Eose ointment ad ... 3 3 — 32. 
M. 

Instead of an ointment we may use oxide of zinc one 
drachm to the ounce of linseed or other oil. Shoe- 
maker (402) advises the application of equal parts of 
oleate of mercury and olive oil. 

In sub-acute and chronic cases a more active treat- 
ment is necessary. Here our aim is not so much to 
allay inflammation as to stimulate the skin. To this 
end we may use the soap and salve treatment of Hebra, 
which renders such good service in chronic cases of ec- 
zema. It consists of frictions with green soap, soft 
soap, or better the tincture of green soap, composed of 
two parts of the soap and one part of alcohol, followed 
by a soothing ointment, such as the oxide of zinc oint- 
ment. Some of the soap is poured or placed upon a 
piece of flannel, this dipped in hot water, and then 
rubbed actively upon the part to remove all the tops 
of the pustules or papules, and leave the surface a lit- 
tle raw. Then the soap is all washed off, and the part 
covered with the ointment spread thickly upon old 
linen or cheese-cloth. The dressing is firmly bound 
down with a roUer bandage. The ointment is to be 
changed two or three times a day, but the soap is to 
be used but once a day or every other day. In some 
cases better results will be attained by the use of di- 
eichylon ointment, or Lassar's paste^ with ten or Mr 



176 DISEASES OF THE HAIR AXD SCALP. 

teen grains of salicylic acid to the ounce. • In very ob- 
stinate cases where there is much thickening of the 
skin, the soap may be kept applied to the part like an 
ointment. When sufficient inflammatory reaction is 
produced, emoUient measures, as in the acute stage, 
should be used. 

Our success in treating these cases, will vary with 
the thoroughness with which the dressings are appHed. 
All ointments must be spread on cloths, not on the skin, 
and the dressings must be kept continuously in close 
contact with the affected part. Sometimes a sulphur 
ointment, one half a drachm to two drachms to the 
ounce; an ointment of iodide of sulphur; the ointment 
of the ammoniate (gr. xv-xxx. ad ? j), or the red 
oxide (gr. v-xv. ad 3 j) of mercury will prove useful. 
Robinson (33) recommends the following ointment: 

Ungt. diachyh (Hebra) 

Ungt. zinci oxidi, . . aa | iss — 50. 

Ungt. hydrarg. ammon. . 3iij — 10. 

Bismuth subnitrat. . . 3 iss — 5. 
M. 

He has found cod-Hver oil the best local appHcation 
in strumous subjects. Yeiel (10)^ advises painting the 
affected parts twice a day with a two per cent, solu- 
tion of pyrogaUol in alcohol, and applying dming the 
night: 

Sulphur, lact 

Alcohol, 

Aquae rosae aa 30. 

Mucilag. gum acaciae, . . fTi xx-xxxx. 

M. 

Hans von Hebra's (394) plan of treatment is to epilate 
and shave, and then with a stiff brush to rub in once 
or twice a day some of the following ointment : 

*Ziemssen's Handbuch des Speciellen Patli, u. Therap. p. 235, 



BYCOSIS. 177 



01. fagi. 



Flor. sulph aa 10. 

Pulv. cretae alb 5. 

Adeps 

Sapo. viridis aa 20. 

M. 
and cover with flannel. Devergie (387) recommends 
painting the part every four or ^ve days with a solution 
of nitrate of silver, one part, in ^ve of water by weight. 

Behrend (42) has obtained good results by scraping 
the affected parts with the dermal curette and dressing, 
with a simple ointment or oil. All abscesses must be 
opened. 

Our rule of treatment then is in acute cases to allay 
inflammation by emollient dressings; in chronic cases 
to stimulate. In all cases to epilate, at least from pus- 
tules, and where possible to have the patient shave. 
The dry and reddened skin sometimes left after the 
disease has run its course is to be treated with hot water 
sopped on for ^ve minutes once or twice a day, and 
some simple ointment to protect the skin from dust 
and exposure to the weather. 

Sycosis affecting other locations than the beard is 
to be treated by epilation and emollient ointments. 

Prognosis. — This is one of the most obstinate of dis- 
eases, specially in such cases as are due to occupation. 
Left to itself, when once under headway, it shows no 
tendency to get well, and has been known to last 
twenty or thirty years. Even under the most judi- 
cious treatment it is an obstinate disease, taking weeks 
or months before a cure is effected. Relapses are ex- 
ceedingly liable to occur, and these sometimes show a 
disposition to recur at certain seasons. Unless the hair 
is carefully withdrawn from the inflamed follicles per- 
manent baldness may be caused. But the disease is 
not dangerous to life, and it is curable. 
12 



PAET III. 

PAEASITIC DISEASES OF THE HAIE. 

Trichophytosis.— Favus.— Pediculosis.— Beigel's 
Disease. 



CHAPTER XII. 

TRICHOPHYTOSIS CAPITIS. 

Synonyms. — Herpes tonsurans; Herpes circinatus; 
Herpes squamosus (Cazenave); Tinea tonsurans; 
Tinea tondens (Mahon); Trichonosis farfuracea (De- 
vergie); Porrigo furfurans (Devergie); Porrigo tonsoria 
(Alibert); Trichosis tonsurans (Wilson); Trichosis 
pilyriasica seu furfuracea (Wilson) ; Trichomykosis 
(Gruby); Dermatomykosis trichophytina; Phytoalope- 
cia seu Trichomyces tonsurans (Malmsten); Ehizo- 
phyto-alopecia (Gruby); Dermatomykosis tonsurans 
(Kobner); Squarus tondens (Mahon); French, Herpes 
tonsurante, Teigne tondante (Mahon); Teigne tonsu- 
rant, Teigne annulaire (Payer); Teigne herpetique fur- 
furacee (Gibert); Trichophytie tonsurante (Hardy); 
Trichophytie (Gruby); Porrigine tonsurantie (Alibert); 
Dartre furfuracee arrondie (Alibert); L'herpes circine 
parasitaire; German, Scherende Flechte; English, 
Eingworm of the scalp; Slav. Eingskurv. 

Definition.— A contagious parasitic disease of the 
hairy scalp, due to its invasion by the Trichophyton 
fungus; and characterized by the formation of partially 
bald, scaly, more or less circular patches, in which 
^^ stumps" of broken-off hair will be found. It is a 
disease pecuhar to children and runs a chronic course. 

Symptoms. — Eingworm of the hairy scalp begins, like 
ringworm of the body, by the formation of a small, 
round erythematous spot upon which ephemeral vesi- 
cles and pustules soon form, which rapidly go on to 
desquamation. Or the spot may become covered with 
furfuraceous scales without the appearance of vesicles 



182 



DISEASES OF THE HAIR AND SCALP. 



or pustules. This stage is so rapid in its course, and 
gives so little annoyance to the patient, that it is sel- 
dom brought to the notice of the physician. The patch 
spreads, the hairs become early affected, and then we 
have the typical patch of the disease before us. This 
is circular in shape; denuded of hair, though not com- 
pletely bald; covered with a greater or less amount of 
scales; and more or less raised above the surface of 




'^iri^^ii^ni 



Ringworm. 



the scalp. There may be only one patch upon the 
head, or there may be a number of them. The size of 
the individual patch may be quite small or it may be 
as large as a silver dollar. If several patches occur 
close to each other, they may coalesce and form a huge 
patch, which may involve the whole top of the head. 
The color of the patch varies somewhat; it may be 
reddish, gray, slate, greenish, bluish or even blackish. 
The color depends upon the amount of scahng present, 



l^iliCHOPHYTOSiS CAPITIS. l8S 

upon the complexion of the individual, upon the ex- 
tent to which the inflammatory process has gone, and 
upon the admixture of dirt or foreign matter. If the 
inflammation is but sHght, and the complexion is 
medium, the patch will be grayish or reddish. In 
dark-skinned subjects the color is apt to be slate. If 
in a strumous subject, and pustulation has taken place, 
we will meet with greenish or blackish patches. A. 
K. Robinson (33) draws attention to the fact that some- 
times the central part of a patch may be gray or slate 
color, and the periphery yellowish or blackish brown 
from the drying up of the vesicles at the margin. 
Probably *^ slaty -gray " will best describe the color of 
the majority of the patches. 

The amount of scaling is rarely excessive, and, 
though at times abundant, never reaches to the for- 
mation of thick mortar-like crusts such as we meet with 
in favus. In a case complicated with eczema, arising 
either spontaneously or from over treatment, thick pur- 
ulent crusts may form, but, of course, quite independ- 
ently of the ringworm. Upon the removal of the scales, 
the exposed scalp will be found reddened, swollen, 
and, it may be, oedematous and tender. In chronic 
cases the scalp will be merely reddened and scaly, and 
sometimes of goose-flesh appearance. 

The condition of the hairs is characteristic. They 
are affected very early in the course of the disease, be- 
coming dry, lustreless, opaque, brittle, twisted, and 
readily breaking off upon the slightest traction, or of 
their own accord. They lose their elasticity, as shown 
by taking a hair and pressing it with the nail, when it 
will readily bend at an angle which it will I'otain. If 
a healthy hair is subjected to the same treatment it 
will soon regain its usual form. Another proof of the 
loss of elasticity, is that when the hair is combed the 
wrong way upon the head, while the healthy hairs will 



lifter 



l84 DISEASES OF THE HAIR AND SCAL?. 

immediately fall into their former position, the affected 
ones will stand up for a momeDt, and then slowly fall. 
The hairs breaking off leave their roots and a small 
portion of their shafts, it may be only one or two Hnes 
in length, in the scalp. These are known as ' ^stumps, ' ' 
and are pathognomonic of the disease. A stump, then, 
is the broken-off shaft and root of a ringworm hair, a 
few lines in length, with a ragged, nibbled-off -looking 
end, which is spht and frayed out, and laden with 
spores. It may present itself as only a minute dark- 
colored dot on the scali^. They are met with in this 
disease alone, and must not be confounded with the 
ends of cut or accidentally broken-off healthy hairs, 
which are not spht or ragged, and do not contain spores. 
The amount of hair present in a patch of ringworm 
varies. Sometimes there will be quite a number of 
long though diseased hairs; sometimes there will be 
only stumps; and sometimes both are present, the 
stumps being superabundant. In a typical patch there 
will be mostly stumps, which give to it the appearance 
of having had the hair cut off clumsily with a dull 
pair of scissors. In some cases, as the result of treat- 
ment, or when the disease has taken an exceptional 
course, the hairs wiU entirely fall out, and thus there 
will be formed a completely bald spot. 

Eingworm affects by preference the vertex and the 
parietal regions, though it may occur anywhere upon 
the head, and at times may pass over upon the skin of 
the face or neck. The only subjective symptom which 
it presents is itching, which is often the first thing 
noticed, and leads to investigation of the scalp. It is 
usually shght. The disease, though chronic in its 
course, and obstinate to treatment, is yet self-limited, 
and does not of itself cause baldness. 

Besides this typical form of trichophytosis capitis, 
the one which we meet with in the vast majority 



TRICHOPHYTOSIS CAPITIS. 1S5 

of cases, there are several other forms or varieties. 
These are pustular ringworm, disseminated ringworm, 
and kerion. The last differs very much from the other 
varieties, and is not always due to the trichophyton 
fungus; therefore it will be reserved for special treat- 
ment. 

The pustular form of ringworm occurs chiefly in ill- 
nourished or scrofulous children. Instead of a scurfy 
place forming, we have pustules produced, and green- 
ish crusts. Sometimes this form may be caused by 
treatment, too strong remedies being used, or remedies 
being improperly applied, and it is especially prone to 
occur in eczematous subjects. It is indeed an impeti- 
ginous eczema, complicating a ringworm of the scalp, 
and may involve a large portion of the scalp. The pro- 
cess is superficial, and if the crusts are removed under 
them wiU be found the characteristic stumps. Alder 
Smith (79) regards this form as especially liable to spread 
amongst schools. It is not the same disease as is the 
deep inflammatory process called kerion. Sometimes 
we meet with a chronic pustular ringworm, which 
presents pustules pierced by hairs. 

Disseminated ringivorm is that form in which, in- 
stead of a single patch or a number of patches occur- 
ring on the scalp, the disease involves more or less of 
the whole scalp, not in the form of patches, but diffused 
throughout the hair. The hair may seem to be growing 
weU, but when the scalp is inspected, we will find it 
scurfy, as in eczema or pityriasis; most of the hair will 
be of normal length and appearance, but here and there 
win be found a number of stumps, either isolated or in 
groups, or there may be only black dots on the surface, 
the roots of broken-off stumps. The long hair may 
be firmly fixed or may come out easily. This form is 
seen most frequently in chronic cases ; and is often over- 
looked, It will sometimes last in this sluggish condi- 



18G DISEASES OF THE HAIR AND SCALP. 

tion for years after the well-defined patches have dis- 
appeared, and the case is considered by the ph^^sician 
and the friends as cured. 

Chronic squamous ringworm is that form in which 
we meet with a patch or patches of the disease which do 
not spread, and which are partially covered with appar- 
ently healthy hair. The patch is still scurfy, and the 
hair may look a little dry, as is commonly met with in 
seborrhoea, but that may be all which arouses our sus- 
picions. Upon careful examination stumps will be 
found close to the scalp, hidden by the long hair. 

The incubation period of ringworm has been shown 
by experiment to be about three days. Its rate of 
growth is rapid, a spot as large as a ten-cent piece may 
develop in forty-eight hours, and attain the size of a 
fifty-cent piece in twenty-four hours more. When it 
has reached the size of a silver dollar, it, in most cases, 
ceases to enlarge. The fife of the fungus is also lim- 
ited. Though the disease may have lasted many years 
in a child, it tends to get well as the child reaches the 
age of puberty. 

The scalp is not the only hairy region affected by 
the trichophyton fungus. The beard is its frequent 
habitat. It may also occur upon the pubes and in the 
axilla, and give rise to appearances somewhat similar 
to those met with in ringworm of the beard. 

Etiology. — Trichophytosis capitis is due to a single 
cause, the implantation and growth of the trichophy- 
ton fungus. This view is one now accepted by all 
dermatologists, though up to quite recent years, there 
were some eminent ones who beheved it to be a disease 
of nutritive debihty . Thus Wilson (33) taught ' ' that it 
was essentially an arrest of development of the hair- 
ceUs and the cells of the rete mucosum. That the ceUs 
retained their primitive molecular character, and the 
granules taking on a proliferous growth are converted 



TRICHOPHYTOSIS CAPITIS. 187 

into a tissue closely resembling a mucedinous vegeta- 
tion." 

The fungus gains lodgment in the upper layers 
of the epidermis, after the most superficial layers 
are removed in some way, and from its point of 
entrance, spreads. Liveing (452) thinks that the fun- 
gus is not the essence of the disease, but plays a sec- 
ondary, though important part, in its development. 
His reasons are the following: Fnst. — The food of 
this kind of vegetable parasite is dead or dying struc- 
tures. Secondly. — The development of the fungus is 
not always in proportion to the changes present in the 
skin and hair, showing that other causes are at work. 
Thirdly. — In many cases the comparatively healthy 
hair of the whole scalp loses its lustre and becomes 
harsh, dry, brittle and more opaque than in health, 
without the growth of the fungus beyond the ring- 
worm patches, and this condition may persist for 
months after the parasitic growth has disappeared. 
Fourthly. — If the fungus were the essence of the dis- 
ease we should expect the malady to be less capricious 
in its nature. 

The disease is very coutagious, much more so than 
is favus. It is nearly always endemic and sometimes 
epidemic. When it gains entrance into a school or 
children's hospital or asylum, it spreads with great 
rapidity, and such institutions are the most important 
agents in keeping it alive. Bergeron (45) has shown 
that in France it is more common in cities than in the 
country. It attacks children almost exclusively. It 
is rare to meet with it after puberty, excessively rare 
to see it on the head of an adult, and very infrequent 
in infants. This shows tliat it requires, like other 
parasites, some peculiar condition of the soil for its 
growth, though what that condition may be is not yet 
determinecl. It attacks all classes of children, the rich 



188 DISEASES OF THE HAIR AND SCALP. 

and the poor, the clean and the uncared for. It occurs 
often amongst strumous children, and those who are 
badly nourished; but as these children are found most 
frequently in those classes which Hve under other con- 
ditions favorable to infection, it is difficult to determine 
the exact predisposing force of the diathesis. When 
the disease gains entrance into asylums and schools it 
does not show any disposition to spare the healthy and 
robust children. Tilbury Fox (12) taught that chil- 
dren of lymphatic temperament were prone to the 
disease. 

The means of infection are mediate and intermedi- 
ate. Thus, it is readily conveyed directly from the 
body or head of one infected person to the head of 
another, or from the body of a child to its owm head, 
ringworms sometimes passing over from the non-hairy 
to the hairy parts. It may also be communicated 
from animals, the disease being common in cats and 
dogs, and it is met with in cows, horses, rabbits, squir- 
rels and other domestic or pet animals. In epidemics 
of ringw^orm in children's hospitals, the air of the 
room has been found loaded with floating spores. The 
most common means of mediate contagion are hats, 
caps, brushes, and combs. 

Pathology. — The disease is caused by the vegeta- 
ble fungus called tricophytoji tonsurans or Achorion 
Lebertii. This consists of myceha and conidia, which 
bear a close resemblance to those of the penicillium 
glaucum. It is, without doubt, a distinct species of 
vegetable grov^h, resembhng (though not the same as) 
the Achorion Schoenleinii, as inoculations made with 
pure cultures produce ringworm alone. On the other 
hand inoculations w^ith pure cultures of the Achorion 
Schoenleinii give rise to favus alone. 

In the hair the conidia are far more numerous than 
the myceha, and sometimes are present in such num- 



TRICHOPHYTOSIS CAPITIS. 189 

bers as apparently to burst the hair. The conidia are 
often found arranged in rows parallel with the long 
axis of the hair. Sometimes they are scattered irregu- 
larly through the hair; usually they are so numerous 
about the bulb and root as to appear crammed together. 
They are round, highly refractive bodies, of a grayish 
or pale green color, and a diameter of from .0021 mm. 
to .0035 mm. 

The mycelia are often absent from specimens ex- 
amined. When present they run through the hair in 
its long diameter, and are long, jointed and wavy. 
Their diameter varies from .0018 mm. to .0026 mm. 

The hair in ringworm of the scalp is early affected, 
the first point attacked being, according to Taylor (486) 
that portion of the shaft immediately on a level with 
the surface of the skin, from which point it spreads 
up and down. The cortical substance in its peripheral 
part is the most frequent and earliest seat of the fun- 
gus; but the whole hair is frequently involved. Ac- 
cording to most observers the bulb is invaded to only 
a slight extent and the papilla and root-sheaths are 
spared. A. E. Eobinson (33) has met with the spores 
and mycelia in the root- sheath and even in the perifol- 
licular tissue. However, as a rule it may be stated 
that the part of the hair most infected is above the 
neck of the follicle. It grows up to a long distance in 
the shaft, but seldom if ever to the point of the hair. 
When present in the hair, in small amount, the hair 
preserves its cuticle entire, and looks scarcely altered. 
When present to such an extent as to cause fracture 
of the hair and the formation of stumps, the cuticle 
will be broken, the whole stump will be disorganized, 
and its end frayed out. Often the hair under the 
microscope seems as if it had burst at many points 
and allowed the spores to escape. In such a case the 
spores will be found lying along the outside of the hair- 



190 DISEASES OF THE HAIR AND SCALP. 

shaft, and grouped and scattered about the fractured 
portion. 

The amount of nritation caused by the fungus will 
vary with the amount of the fungus and its seat. 
When only a few spores are present, and these are 
superficially seated, the scalp will be only shghtly red- 
dened and scaly, or there may be some vesiculation. 
When the spores are present in greater number, and 
have penetrated into the hair-foUicles, they will cause 
more redness of the scalp, a greater or less amount of 
perifollicular inflammation, and tumefaction of the 
scalp. The extreme degree of irritation is that met 
with in kerion, as we shall learn in another place. 
Behrend (3) well points out the difference between the 
growth of the fungus in ringworm and favus, when 
he says: " The achorion remains for a long time con- 
fined to the superficial layers of the hair, growing 
quite high up in the shaft, while the trichophyton 
involves in a few days the whole thickness of the hair 
and makes it brittle, so that ifc breaks upon the shght- 
est traction. On this account the hairs of favus pre- 
serve their normal lustre and consistence, while those 
of ring^vorm very soon lose the same. ' ' 

Diagnosis. — The diagnosis of atypical patch presents 
no difficulty, as there is no other disease which occurs 
in the form of round, partially bald, scaly patches, 
with disorganized hairs and ' ' stumps ' ' growing in 
them. But at times cases do occur which are not so 
easily made out. Seborrhoea, psoriasis, favus, lupus 
erythematosus, and eczema occur upon the scalp in 
the form of scaly patches; alopecia areata causes cir- 
cular bald patches; and the other forms of alopecia 
denude the scalp of hair. From these, then, under 
certain conditions, ringworm of the scalp must be 
differentiated. 

1. From seborrhcea sicca capitis. — Seborrhoea may 



TRICHOPHYTOSIS CAPITIS. 191 

appear at any time of life. Eingworm is almost ex- 
clusively confined to childhood. Sebonhoea has no 
history of contagion, and is variable in its course, 
getting better and worse of itself. In ringworm it is 
generally easy to trace the case back to its source of 
contagion, and the disease once started is progressive, 
showing little tendency to get well of itself until pu- 
berty is reached, when it generally disappears com- 
pletely, never to return. Seborrhoea involves the scalp 
pretty generally and uniformly; if it form patches 
they are irregular and not sharply defined. Ringworm 
usually occurs in one or more isolated sharply defined 
patches, affecting by preference the vertex. The scales 
of seborrhoea are prone to heap up into thick masses, 
and are tenacious and greasy to the feel. In ring- 
worm they are seldom heaped up, are readily detached, 
and are not so greasy. Seborrhoea may cause bald- 
ness, this condition being usually preceded by a progres- 
sive thinning of the hair- calibre over a series of years, 
and affecting the top of the head. With the increase 
of the baldness there will be a decrease of the sebor- 
rhoea, and the baldness wiU be complete and permanent. 
In seborrhoea there is a complete absence of the 
tichophyton fungus, and '^ stumps." 

2. From psoriasis. — Psoriasis occurs in the form of 
thick, crusted patches scattered more or less over the 
whole scalp, and tending to form a row of characteristic 
lesions along the margin of the hair upon the forehead. 
Ringworm is more apt to be confined to the vertex, its 
patches are scaly, and if it encroaches upon the non- 
hairy parts, it will form a characteristic patch of ring- 
worm of the body. Psoriasis does not affect the hair; 
ringworm causes partial alopecia In psoriasis there 
win be a history of relapses in many cases; this is 
entirely absent in ringworm. In psoriasis there is no 
history of contagion: in lingworm there is such a 



192 DISEASES OF THE HAIR AND SCALP. 

history in the majority of cases. Psoriasis rarely if 
ever occurs on the scalp alone, and therefore charac- 
teristic patches of the disease will be found upon the 
arms or elsewhere; ringworm is quite commonly con- 
fined to the scalp. 

3. From favus. — Favus is an imported disease in 
this country in the vast majority of cases, and hence 
is seen mostly in foreigners; ringworm is endemic 
and often epidemic. Favus presents either the path- 
ognomonic cupped crusts, or else thick masses of mor- 
tar or asbestos-hke, grayish, friable crusts; ringworm 
has no cupped crusts, and the scahng is but sHght. 
Favus causes distinct, irregular, perfectly smooth, 
atrophic-looking, red, bald patches, scattered over the 
whole scalp; ringworm causes only partially bald, 
sHghtly scaly, circular, grayish patches, confined most 
often to the vertex or side of the head, and the scalp 
is not atrophic. In favus the hah- is affected second- 
arily, and readily pulls out entire with its root; in 
ringworm the hair is early affected, and when pulled 
on it breaks easily and leaves its root behind in the 
scalp, forming the '^ stump." Favus is a very chronic 
disease, shows httle tendency to get well of itself, and 
often lasts until late in life; ringworm is not so chronic, 
is most often seen in children, tends to get well of it- 
self as its subject reaches puberty, and is rarely met 
with in adults. Under the microscope the mycelia 
and conidia of favus scales are seen to be sHghtly larger 
than those of ringworm. Its conidia are more mani- 
fold in shape, being ovoid, often elongated, and some- 
times dumb-beU shaped, while the conidia of ringworm 
are uniformly round. In favus the hairs are mostly 
invaded by myceha which may be seen as long fila- 
ments in the hair; in ringworm the conidia are found 
in superabundance, often exclusively, and so numerous 
at times as to bm^st the hair. 



TRICHOPHYTOSIS CAPITIS. l9^ 

4. From lupus erythematosus. — The only resemblance 
it ha,s to ringworm is the formation of a scaly bald 
patch; but there is no history of contagion, the course 
of the disease is slower, the hair is affected secondarily, 
the patch has a cicatricial depression in the centre, and 
is of irregular outline. There is no fungus to be found. 

5. From eczema. — Squamous eczema is the form 
which is most apt to be confounded with ringworm. 
At times a pustular eczema may complicate a case of 
ringworm, or a case of disseminated ringworm may 
simulate a pustular eczema. 

Squamous eczema. — Squamous eczema has no his- 
tory of contagion; in ringworm the history of contagion 
can generally be made out. Squamous eczema attacks 
all ages from infancy to old age; ringworm is usually 
met with in childhood alone, sparing infants and not 
lasting after puberty is reached. Squamous eczema 
often is diffused over the whole scalp, and when it 
does occur in patches they are not sharply defined; 
ringworm occurs in more or less circular, sharply de 
fined patches. Squamous eczema is very itchy and the 
scalp shows scratch-marks; ringworm is but slightly 
itchy and scratch- marks are not commonly found. The 
scales of squamous eczema can be removed in plates 
though they are thin; the scales of ringworm are more 
powdery and bulky. The hair in squamous eczema is 
not affected, is firmly implanted in the scalp, and when 
epilation is attempted, it is painful; in ringworm the hair 
is early affected, dry, lustreless, and either comes out 
readily and painlessly on slight traction, or breaks off. 
In squamous eczema there are no " stumps; " in ring- 
worm they are always present, and give the diagnosis, 
even if eczema occurs as a complication of the ring- 
worm. 

Pustular eczema. — A pustular eczema Avill only 
need to be differentiated "^ '^^ that rare form of dis- 
13 



194 DISEASES OF THE HAIR AND SCALP. 

seminated and pustular ringworm. Here the condi- 
tion is one of ringworm plus eczema. The diagnosis 
is made by the presence or absence of the characteristic 
hairs and stumps of ringworm. In doubtful cases the 
microscope will decide. 

6. From alopecia areata. — In typical examples of 
this disease there should be no mistake in diagnosis. 
The perfectly smooth, non-scaly, non-pruriginous, per- 
fectly bald patch of alopecia areata is in strong contrast 
to the rough, scaly, more or less itchy, partially bald 
patch of ringworm in which are stumps and diseased 
hairs. Alopecia areata comes on suddenly, often with 
antecedent symptoms of headache and pain in the scalp, 
and the patch is formed at once. Ringworm comes on 
with comparative slowness, and without antecedent 
symptoms. Alopecia areata occurs at a later period of 
hfe than does ringworm, as a rule; and if a circular, 
circumscribed bald spot occur in an adult, it is far more 
likely to be one of alopecia areata than of ringworm. 
Sometimes a patch of alopecia areata wiU present a 
number of black dots, the unfaUen roots of hair, which 
may bear some resemblance to the stumps of ringworm, 
but if they are examined under the microscope, the 
root will appear shrunken and atrophied, and there 
will be an entire absence of the spores and mycelia of 
ringworm. Sometimes a patch of ringworm wiU be 
perfectly smooth and without stumps. This is usually 
the result of treatment. Stumps wiU be found else- 
where on the scalj), or diseased hairs, if the disease be 
ringworm, and the fungus will be found in the scales 
from the border of the patch. 

Y. From other forms of alopecia. — The history and 
course of other forms of baldness, as well as the time of 
then appearance, are so different from what obtains 
in ringworm, as hardly to give rise to any difficulty. 

The recognition of the presence of the fungus in the 



TRICHOPHYTOSIS CAPITIS. 195 

hair by the aid of the microscope is easy after a Httle 
practice. All that is needed is a microscope with a 
lense magnifying some 250 diameters, a slide and cov- 
ering glass, and a drop of liquor potassse with or with- 
out glycerine. After dropping the liq. potass, upon 
the hair, (a stump is the best one to examine,) and put- 
ting on the covering glass, wait a few minutes before 
looking at the specimen. The mycelia will be recog- 
nized as long, branched, jointed threads running up the 
hair-shaft, and the spores will be seen as small, round, 
refracting bodies in rows or closely packed together. 
Care must be exercised not to mistake air-bubbles for 
spores. Air-bubbles are recognized by their change ol 
color upon changing the focus of the microscope. It 
is also possible to mistake the striated condition of the 
hair for the mycelia, but a httle care and practice will 
prevent this. 

Dyce Duckworth (421) has pointed out a ready means 
of determining the presence of fungus in hair, which 
is by laying the suspected hair in chloroform, and al- 
lowing the chloroform to evaporate. If fungus is pre- 
sent the hair will become white or primrose yeUow 
where the fungus is. But this reaction is not pecu- 
liar to ringworm, as it is also found in favus and 
pityriasis versicolor. 

The recognition of the disseminated form of ring- 
worm is often a most difficult task, but it is most 
important for the physician to recognize it, as one such 
unsuspected case may be the cause of fresh epidemics. 
To examine these cases the child should be placed with 
its face to the light and its back to the physician 
Then the hair is to be turned back on the head in the 
opposite direction to its growth. By carefully watching 
the scalp, some stumps will be found here and there; 
and Tilbury Fox has shown that, if there are any 
diseased hairs present, they wiU stand out from the 



19(3 DISEASES 0^ THE HAIR AND SCALP. 

head after the normal hairs have fallen into thsir 
places. 

Treatment. — That nothing is easier to cure than a 
recent case of ringworm on the body all wiU agree. 
That a chronic case of ringworm of the scalp is very 
difficult to cure all writers and observers attest. Our 
treatment must vary with the stage of the disease. 
External apph cations are far more valuable than in- 
ternal medication; and indeed the former may be relied 
on in the vast majority of cases for the cure of the 
disease without recourse to the latter. 

General Treatment. — If the patient is evidently 
strumous or any way out of health, of course he 
should be given the internal treatment best fitted 
to his case, such as cod-liver oil, iron, arsenic, 
etc. Attention to the patient's general surround- 
ings is in most cases of more service than giving 
medicines. An infected child should be isolated as 
much as possible, and by all means kept out of school. 
Isolation can and ought to be rigidly practiced in aU 
children's asylums, and the attending physician should 
see to it that the infected children do not come in 
contact with the healthy ones. In private families 
isolation cannot be so readily accomplished, but much 
may be done to prevent the disease spreading to other 
children in the family by having the infected child 
sleep by itself; by providing towels, brush and comb 
for its special use; and letting it wear a close-fitting 
hnen cap. Other children should not wear the infected 
one's clothing, for not only do caps carry the conta- 
gion, but also the coUars of jackets and coats. The 
patient's head must be kept saturated with an antipar- 
asitic oil, lotion, or ointment during the whole course 
of treatment, to kiU the loose spores and prevent them 
from being carried to other heads. For this purpose 
we may use either a two per cent, salicylated oil, that 



TmCHOPHYTOSIS CJAPITI^. 10? 

is salicylic acid in castor oil; a saturated solution of 
boracic acid; a two to five per cent, carbolized oil; a 
solution of hyposulphite of soda, two drachms to the 
ounce; or an ointment of sulphur, one drachm to the 
ounce; or one of the ammoniate of mercury. Of course 
this does not exhaust the list of useful applications, 
but the ones mentioned are probably the best. My 
own preference is for the salicylated oil, as it is odor- 
less and efficient. 

Local Treatment. — In the local treatment of the dis- 
ease our chief reliance is upon the use of parasiticides, 
to which in some cases epilation must be added. The 
remedies that we call parasiticides, such as mercury, 
chrysarobin, pyrogallol, and the lil^e, have been sup- 
posed by some observers to do good, not by any speci- 
fic action, but by the production of inflammation and 
scahng. (We know that the fungus cannot live in the 
presence of pus, and for that reason we employ, in 
very chronic cases, croton oil to produce acute pustu- 
lation. Here the good done is due to the inflamma- 
tion produced by the remedy.) It is true that many 
of them do have this action, but as ringworm can be 
cured by these remedies, without the production of 
inflammation, and as no exfoliation of the epidermis 
caused by them could account for the cure of tricho- 
phytosis pilaris, we must hold that they do act by vir- 
tue of their specific action upon the fungus. 

The first step in the treatment of aU cases is to have 
the head weU washed with soap and water, and all 
crusts removed. After washing, the parasiticide is to 
be applied at once, unless epilation is practised. The 
frequency with which shampooing of the scalp is to 
be repeated will vary with the remedial application 
used. As a rule it may be stated that the longer a 
parasiticide ointment or oil is kept in contact with the 
scalp the better, and it is only to be washed off when 



198 DISEASES OF THE HAIR AND SCALP. 

there is an accumulation of scales^ or for purposes of 
cleanliness. But, as we shall see, some plans of treat- 
ment require daily washing of the scalp. 

Epilation. — Epilation is unnecessary in recent cases, 
but serviceable in chronic cases, and should always be 
practised in the pustular form. It is by no means as 
effectual in ringworm as in favus, because the hair is 
so brittle that it breaks off when palled on and leaves 
its spore-laden root in the scalp. Still, a certain num- 
ber of the roots will be extracted, and this will have 
two good effects, namely; 1. The removal of a cer- 
tain amount of fungus from the scalp; and, 2. The 
mouth of the follicle will be open so that the parasiti- 
cide may gain more ready access to its deeper portion. 
In pustular ringworm the hair comes away readily, 
and thus rehef is afforded to the perif olhcuhtis. Epila- 
tion should be immediately followed by the apphcation 
of the parasiticide. 

Treatment of recent cases. — If we are so fortun- 
ate as to see the case in its early stage, when it is still 
superficial, it will be easy to effect a speedy cure. It 
is in such cases that many vaunted remedies have 
made their reputations. One of the most reUable 
parasiticides is the bichloride of mercury in alcohol, 
(gr. i — iii. ad s j ; or even stronger, if used by the physi- 
cian), sopped on three or four times a day. Here as 
elsewhere the best means of applying the solution is a 
little absorbent cotton on a wooden tooth-pick, or any 
small stick. Caution must be had to use a fresh swab 
each time, otherwise a remnant from the previous 
apphcation will dry on the swab, and we soon mU 
have a much stronger solution than we want. Vari- 
ous other remedies are useful, such as sulphiu-ous acid 
in full strength; sulphuret of potassium, 3ss-j, water 
3 j ; hyposulphite of soda 3 iij, water | j ; sulphite of 
soda 3 j-ij, lard 1 1; sahcylic acid, two to five per cent. 



TRICHOPHYTOSIS CAPITIS. 199 

in castor oil; a saturated solution of boracic acid; car- 
bolic acid, ten to twenty per cent, in glycerine, varying 
with the age of the child; sulphur ointment; tinct. of 
iodine, and others. When the disease is still recent, 
but the hairs have become invaded and a characteristic 
patch has formed, the hair is to be cut from the patches 
and a slight area around them. In this stage any of 
the just mentioned remedies may be used. It is in 
such cases that chrysarobin (chrysophanic acid) effects 
its most briUiant cares. Fayrer (42G) was the first, in 

1874, to draw the attention of European physicians 
to its use in the treatment of ringworm as occurring in 
India, where it was used under the name of Goa pow- 
der, araroba, or po'de Bahia. It w^as first used in 
the form of an ointment, and Da Silva Lima (474) in 

1875, reported excellent results from one composed of 
Goa powder, 20 grains, acetic acid, 10 drops, ointment 
of benzoin, one ounce. It has since then been used 
successfully in the form of an ointment of five to 
twenty per cent, strength. But this manner of apply- 
ing the drug on the scalp is objectionable, as it is 
exceedingly irritating, and frequently causes intense 
oedema and cellulitis of the scalp and face. The best 
method of using it is in the form of a "pigment" 
composed of 

Chrysarobin, . . . 10 parts. 

Flexible collodion, . . 90 " 

Castor oil, .... 3 drops. 
M. 

This is to be painted on the scalp with a stiff brush, 
and renewed as often as the film loosens or scales off. 

The oleates of mercury or copper in five to ten per 
cent, strengths according to the age of the child are 
often useful, especially the first. The ointments of 
the ammoniate and red oxide of morcurv are i'avo rites 



^^ 



SOO DISEASES OF THE HAIR AND SCALP. 

with many. Tincture of iodine will sometimes act 
brilliantly in these cases. 

Treatment of chronic cases. — The chronic cases 
are exceedingly hard to cure, and medical literature 
is rich in methods of treatment. The first requisite 
to success is patience both on the part of the physician 
and patient. As there frequently is need for changing 
from one method of treatment to another before the 
case is cured, it has seemed advisable to give below a 
number of plans which have been found useful by 
competent observers, and have been pubhshed during 
the last twenty-five years in medical journals. 

Tilbury Fox (473 and 12) recommends epilation fol- 
lowed by 

01. cadini 3 iij, 

Sulphur, 3 iij, 

Lard . . . . ad Ij. 

M. 
He directs that the parasiticide be well rubbed in for 
fifteen or twenty itdnutes every morning and night. 
He also recommends the following ointments: 

Sulphate of copper, 

Ammoniate of mercury, aa gr.xx = 1.50 

Oil of cade, 

Sulphur, . . aa 3iij = 12 

Lard, . . . ad 3J = 30 

M. 
If this is too strong the strength is to be reduced by 
adding more lard. Another ointment is: 

Oil of cade. 
Sulphur, 

Tinct. iodine, . aa 3 iij = 12. 

Carbolic acid, . . . gr.xl = 3. 
Lard, . . . . !j = 30. 
M. 



TRICHOPHYTOSIS CAPITIS. 201 

He aims at producing irritation almost to the point 
of suppuration, and if the above ointments do not ef- 
fect this, he prescribes either: 

Corrosive subhmate, gr. iv-vi. 
Acetic acid, . 3 j 
Lard, . ad. ij 



M. 
or: 



iv-vi. 


= 4. 
= 30 


.25-. 


565 


gr. vj 







565 


Sss 


= 


16. 




3j 


= 


4. 




§vj 


= 


200. 





Corrosive sublimate, 
Tinct. of cantharides. 
Nitric acid. 

Distilled water, ad 

M. 

When there are but a few small spots, he blisters 
them, and continues the treatment until the growth 
of diseased hairs is checked. For blistering fluids he 
uses acetic acid, or Costar's paste (iodine 3 iij, color- 
less oil of tar ad 3 j), applied sparingly to small sur- 
faces and blotted off when they begin to smart. If 
much irritation, pain and swelling follow their use, he 
uses a poultice for one or two hours. Blistering may 
be repeated every four to six days. Then epilation 
and one of the above ointments, or the lotion is contin- 
ued until the disease is cured. During the treatment 
the hair is kept either well greased, or soaked with 
dilute sulphurous acid, and covered with a silk cap. In 
the wards of children's hospitals he directs that sul- 
phur be burned to disinfect the air. 

E. A. Brown (414) treats his cases by rubbing the 
patches with rectified oil of tar and covering them 
with a layer, one eighth of an inch thick, of a paste 
composed of tannin, iodine, gum arable and a few 
drops of oil. This is to be left on for three or four 
days, then scraped off, and re-a])plied. 

Saml. Gee (434) gives the following directions for 



202 DISEASES OF THE HAIR AND SCALP. 

treatment. 1. Cut the hair everywhere quite close, 
and keep it cropped close. 2. Wash the scalp twice a 
day with warm water and soap. 3. After drying rub 
well into the scalp. 

Sulphocyanide of potassium, ? ss = 15. 

Glycerine, . . . Jj == 30. 

Water, . . . . gvij ad 200. 
M. 

4. Keep a piece of hnt soaked in the same lotion on 
the scalp day and night, covering it with oiled silk 
and a cahco cap. 

Ladreit de Lacharriere (446) uses in chronic cases 
croton oil followed by poultices, only a small place 
at a time being treated. He employs a cosmetic pencil 
composed of equal parts of croton oil and white wax; 
or of equal parts of cocoa butter and white wax with 
fifty per cent, of croton oil. The mass is melted and 
poured into hollow cylinders with a diameter of half 
an inch. A cure is said to be effected in from six to 
eight weeks. 

Liveing (453) apphes the tincture of iodine in double 
strength every day in extensive cases, and follows it 
with the ointment of the nitrate of mercury; or the red 
or white precipitate ointment with sulphur; or a ten 
per cent, oleate of mercury. 

Startin (481) advises washing the part with soap 
and water, drying and applying a blistering fluid. After 
inflammation has subsided, apply equal parts of oil of 
cade, creosote, and tincture of iodine, and a lotion of 
hyposulphite of soda ( 3 ij ad 1 j). If the skin is sore 
from the use of the above, apply equal parts of white 
precipitate ointment and vaseline. 

Cottle (416) has had most success by using '^hniment 
crotonis " to produce pustulation, after which an oint- 
ment or lotion of sahcylic acid, ten to forty grains to 



TRICHOPHYTOSIS CAPITIS. 203 

the ounce, is applied two or three times a day. Some- 
times he combines oil of cade or carbolic acid with the 
salicylic acid. • If an eczematous condition is present, 
he combines one of the soothing salts of zinc or mer- 
cury with the salicylic acid. 

EiCHARDSON (466) has used ethylate of sodium suc- 
cessfully in a case of chronic ringworm. 

Morris (460) has been very successful with the fol- 
lowing : 

Thymol, . . 3 ss = 2. 

Chloroform, . 3ij = 8. 

Olive oil, . . 3 vj = ad 30. 

M. 
The amount both of the thymol and chloroform is to 
be reduced in young children and when the disease 
tends to become pustular. The oil is to be rubbed in 
gently two or three times a day. The part is to be 
washed with soap and water before the first applica- 
tion, but not subsequently. If at any time there is 
the slightest irritation the rubbing is to be stopped and 
the oil merely smeared on. No cap should be worn in 
the house, as the head is to be kept cool. 

Harrison (436) by a series of experiments upon the 
comparative power of various substances to penetrate 
the scalp, found that the most powerful combination 
of remedies was to apply to a small part of the diseased 
scalp for a few days Solution No. 1., as follows; 

Iodide of potassium, 3 ss = 2. 

Liquor potassse, . 3 j = 30. 

M. 
on pledgets of cotton. This is followed by Solution 
No. 2. 

Corrosive sublimate, gr. iij = .2 

Sweet spirits of nitre, vel. 

Water, ... gj = 30. 

M. 



201 DISEASES OF THE HAIR AND SCALP. 

In this way the head is gone over several times. He 
has treated thirty cases by this plan, curing them in 
about two months. His theory is that the hquor 
potassse softens the hair and conveys the iodide of 
potassium to its root and bulb; then the mercury pene- 
trates to the same place, meets the iodide of potassium 
and forms the biniodide of mercury just w^liere it is 
w^anted. 

FouLis (428) claims to cure his cases in seven days by 
cutting the hair short over the affected parts, or off 
the Avhole head, if the disease is extensive, and then 
rubbing in a hberal quantity of spirits of turpentine. 
When the scalp begins to smart it is to be washed 
with warm water and a ten per cent, carbolic soap 
It is then to be dried and painted with two or three 
coats of the tincture of iodine. When the scalp is dry 
the whole head is to be anointed with carbohzed oil, 
1 in 20. The treatment is to be repeated once or twice 
a day. In very severe cases it is weU to use a solution 
of ten grains of iodine in one ounce of turjDentine. 

Geo.T. Elliot (424) recommends painting the part 
with the foUowmg: 

Pyrogallol (pyrogaUic acid), 3 ss-ij = 2-8. 

Salicylic acid, . . 3 ss = 2. 

Flexible collodion, . | ij = 60. 
M. 

Lesser (451) has found a ten per cent, solution of 
corrosive sublimate applied twice a day the most use- 
ful parasiticide. 

Kaposi (19) regards as specially useful the following: 

Oil of birch, 15. 



Tinct. of green soap, 
Precipitated sulphur, 
Spirits of lavender, 
Balsam of peru, 
M. 



25. 
10. 

50. 
1.50 



TRICHOPHYTOSIS CAPITIS. 205 

Gamberini (59) recommends, 

Flowers of sulphur, ... 10. 

Camphor, 10. 

Lard, 30. 

M. 

Alder Smith (T9) has often been successful in treat- 
ing ringworm with, 

Boracicacid, . 3ivvelq.s. = 16. 

Common ether, | v . =150. 

Alcohol, . ad § XX . = 600. 
M. 

which forms a saturated solution of boracic acid. The 
hair is to be cut, and all scurf and sebaceous matter 
washed from the patches with hot water and soap. 
This washing is to be repeated every morning. After 
dryiQg the head, the solution is to be well dabbed and 
pressed into the hair follicles with a small fine sponge 
for ten minutes. Eepeat three to six times a day. 
During the first few weeks of treatment the solution 
is to be applied over the whole head. No pomade 
should be used during this treatment. Sometimes un- 
der this plan the scalp becomes so dry that the hair 
falls out of itself, and leaves bald smooth patches, sim- 
ilar to what is seen in alopecia areata. In very chronic 
cases, and especially in disseminated ringworm, his 
chief reliance is upon croton oil. In the disseminated 
variety, a minute drop is placed upon every stump, or 
black dot. If there are only a limited number of these, 
the oil is to be pressed into the follicles by means of a 
fine, blunt gold pin. A pustule results, the hair loosens 
and can be readily pulled out. If the hair breaks off, 
the oil is to be re-applied when the pustule has healed. 
A large thin poultice worn day and night under an oil- 
skin cap will hasten suppuration and aid in extracting 
the hair. In a chronic case, which has resisted all 



206 DISEASES OF THE HAIR AND SCALP. 

other forms of treatment, croton oil is to be applied to 
a small place, not much larger than a ten cent piece, 
at a time and followed by a poultice. If one applica- 
tion does not give rise to suppuration, repeat until arti- 
ficial kerion is produced, the scalp being swollen, ten- 
der, puffjj and pustular. The hairs are now loosened 
and are to be removed, and soothing remedies applied, 
as in kerion. A second patch is to be attacked as soon 
as the first one is progressing favorably, and so all dis- 
eased portions are to be treated. This plan is to be 
kept for a last resort. If a bald spot remain after the 
use of croton oil, a stimulating lotion is to be ordered. 

The same author recommends the removal of obsti- 
nate disseminated diseased hairs by electrolysis, which 
of course destroys the foUicle. 

Leftwich (450) advises cutting the hair close from and 
around the patch, and painting the scalp with an alco- 
hoHc solution of the iodide of mercury, made by add- 
ing calomel to tincture of iodine, and using the super- 
natant colorless fluid. When the soreness caused by 
it has passed off, an iodine plaster is to be applied, and 
left on for a week or so. This plaster is made by add- 
ing a half drachm of sohd iodine to an ounce of plaster 
mass, and spreading it on kid. By this treatment the 
doctor expects to cure his cases in a month. 

The oleate of mercury, five to ten per cent., is highly 
thought of by many in chronic ringworm. In Dr. 
Geo. H. Fox's service, in the New York Skin and Can- 
cer Hospital, I have seen many cases cured by system- 
atic epilation and inunctions of two to three per cent, 
salicylated oil. 

The rapidity of cure wiU depend largely upon the 
thoroughness with which directions are foUowed, and 
the physician should make the applications himself 
during the first few days, until some one of the family 
becomes properly trained. The results are often best in 



TRICHOPHYTOSIS CAPITIS. 20 T 

hospitals because of the constant supervision of the 
house physicians and the skillful manipulations of the 
trained nurses. 

After a case has recovered from trichophytosis a dry 
and scaly condition of the scalp may be left. This 
condition may readily be cured by 

Hydrarg. ammon . . . 3ij = 3. 

Hydrarg. chlor. mitis . . 3iv=: 6. 

Vasehne . . . . ad §i =3u. 
M. 

a favorite formula of Dr. E. B. Bronson of New York. 
Or a sulphur ointment may be used of the strength of 
one drachm to the ounce. 

When to stop treatment is a very important matter 
to determine. The mistake is often made of stopping 
as soon as the hair is growing fairly. We should sus- 
pend treatment as soon as the scalp is no longer scurfy, 
the hair is growing healthily, the microscope no longer 
shows the presence of fungus in the hair, and there are 
no stumps to be found in the scalp. The patient should 
be kept under observation for a few months, and if 
these same conditions are preserved he may be dis- 
charged as cured. 

Over-treated cases are sometimes met with, either 
too strong remedies having been employed, or proper 
remedies continued too long. The condition present is 
usually pne of eczema, the original disease perhaps 
having been cured. By suspending all treatment from 
time to time we will easily avoid this. 

Prognosis.— The prognosis is good, though the dis- 
ease is often very rebellious to treatment. A too 
speedy cure should not be promised, and three to six 
months must often be given to the treatment of a 
chronic case. It must be borne in mind that the dis- 
ease is in most cases self -limited, and the most hiveter- 



208 DISEASES OF THE HAIR AND SCALP. 

ate cases tend towards spontaneous recovery with the 
approach of adult years, rarely lasting later than the 
fifteenth or sixteenth year. This should prevent us 
from making use of such remedies as croton oil except 
when other things have failed, as it produces at times 
permanent baldness if not carefully employed. Cases 
have been known to spontaneouly heal in from one to 
three years. Baldness rarely follows the disease ex- 
cepting as the result of treatment. 

Granuloma tricliopliyticum. — Under this title Ma- 
joccm (458), in 1883, described a form of ringworm at- 
tacking hairy regions which differed from sycosis and 
kerion, and consisted of round tumors of normal skin- 
color, painless, non-scaly, surrounded by a colorless 
areola, of the size of a half walnut, at first elastic, 
then soft and fluctuating hke an abscess. In the middle 
of each is a trichophytic hair, or a filament of fungus. 
Histologically the tumors have the characters of a sub- 
cutaneous granuloma, young granulation cells with 
blood-vessels and giant cells. Majocchi believes that 
in these cases the fungus penetrated into the corium 
through the hair follicle and sebaceous gland. 



CHAPTER XIII. 

KERION. 

Synonyms: — Trichomykosis capillitii (Auspitz); Ves- 
pajo del Capillizio, Vespajo tricofitico del Capillizio 
(Ital). Tinea kerion; Kerion celsi. 

Definition. — A more or less chronic inflammation 
of the hairy scalp, characterized by the formation of a 
prominent, boggy, uneven swelling, studded with 
numerous foramina out of which oozes a sticky, 
mucoid substance. The tumor at times undergoes 
suppuration, and generally follows upon ringworm of 
the scalp. 

Symptoms. — Kerion derives its name from a Greek 
word meaning a honeycomb. The Italian name signi- 
fies a wasp nest. It has generally been regarded as a 
stage of ringworm of the scalp, but it is better to look 
upon it as a form of that disease rather than a stage, 
as it may be produced artificially and independently 
of trichophytosis. It is analogous to the nodular 
swellings met with in trichophytosis barbae. Tilbury 
Fox (502), in 1866, first identified kerion as a form of 
ringworm. 

As ordinarily met with the disease or condition fol- 
lows upon a simple patch of ringworm. The affected 
part becomes red, oedematous, swollen, and boggy; it 
may be purplish in color. Its surface is glazed, un- 
even, and studded with a number of yellowish suppur- 
ating points, or with foramina out of which oozes a 
sticky, gelatinous, viscid, transparert fluid. At times 
if the inflammatory process is more intense, the swell- 
14 



Ij 



w 



sio 



DISEASES OF THE HAIR AND SCALP. 



ing may reach considerable size, and instead of a mu- 
coid fluid escaping from the foramina, true suppura- 
tion may take place attended with a sero-purulent dis- 
charge. The amount of the discharge is in proportion 
to the amount of inflammation present, and the depth 
to which the process goes. The swelling is rounded or 




Kerion. 



oval in shape, and varies in size; usually it is one or 
two inches in diameter, but it may become as large as 
a turkey's egg. 

The hair on the affected part at first has the charac- 
teristic appearances of that of ringworm, when kerion 
follows that disease, being broken off, and presenting 
stumps. The pustules of the early stage of the disease 
form about the hairs at their exit from the scalp. 
Later the hairs loosen, and are easily plucked; as the 
inflammation progresses, they fall, and from the open- 
ings of the hair-follicles the mucoid or sero-purulent 



^11 KERIO^. 

discharge takes place. If the disease is not properly- 
managed, or if the inflammation is very intense, per- 
manent baldness may result from destruction of the 
hair follicles. 

The subjective symptoms are more or less pain; ten- 
derness on pressure; at times itching and burning. 
The course of the disease is chronic, and it may last a 
very long time. At times the posterior cervical glands 
are enlarged, as is common in inflammatory diseases of 
the scalp. 

Etiology. — The disease is rare. I have met with it 
only three times in six thousand cases. It occurs in 
all classes of society, but affects children especially. 
The scrofulous habit or a poor constitution favor this 
form of inflammation, though it may occur in healthy 
subjects. The exciting cause is, in most cases, the 
trichophyton fungus passing deep down into the hair- 
follicles. It may be produced by over treatment of a 
case of ringworm of the scalp ; or by the application 
of irritants to the scalp quite independently of ring- 
worm; or it may follow eczema or sycosis of the scalp. 
According to Majocchi (503) this condition is some- 
times met with in favus. 

Pathology. — ^When due to the trichophyton tonsu- 
rans, the fungus penetrates deeply into the hair-f oUicles 
and there sets up an inflammation. This wiU vary in 
intensity with the irritation produced. According to 
Atkinson (499), if the irritation goes only to a certain 
extent there will result a purely catarrhal inflamma- 
tion of the hair-follicles, and the production of a mu- 
coid secretion. If the irritation is greater, a suppura- 
tive inflammation will be established, and there will be 
a sero-purulent discharge. Eobinson (33) says, that 
' ' in tinea kerion the glands of th e skin seem to be af- 
fected as well as the hair-follicles, and pour out a nui- 
coid secretion. In this form, though there is no true 



^V2 DISEASES OE' THE HAlii AISTD SCALP. 

suppurative process, the inflammation in the given 
area is so general, deep, and long-continued that the 
foUicles are destroyed, and permanent alopecia results. " 
Majocchi (503) found the parasite in the hair-follicle, 
along the hair-shaft, and in the connective tissue 
around the hair-follicle; the follicles filled with epithe- 
lial cells, pus corpuscles, spores, and myceha, and the 
sebaceous glands and skin in the neighborhood in- 
flamed. 

We need not here describe the trichophyton fungus, 
as that has been done in the preceding chapter. If 
hairs are plucked from a non-suppurative patch of 
kerion the fungus will be found in abundance in them 
and their sheaths. If suppuration is active in the 
patch the fungus may be destroyed, and it may not be 
found in the hairs. 

Diagnosis. — Kerion is most apt to be mistaken for 
a subcutaneous abscess. It must also be diagnosed 
from a papilloma of the scalp, from a gummatous 
tumor, a sebaceous cyst and a fatty tumor. 

An abscess is not preceded by ringworm, has no his- 
tory of any irritation directly applied to the part, and 
may arise without any antecedent disease of the scalp. 
Kerion is commonly preceded by a ringworm, or there 
is a history of some antecedent disease, or the applica- 
tion of some irritant to the part. An abscess as a rule 
is very painful, and the patient experiences a sensa- 
tion of throbbing in the part. Kerion is much less 
painful and sometimes itchy. Abscesses occur in sub- 
jects of lowered vitality. Kerion often occurs in the 
otherwise robust. The formation of an abscess is ac- 
companied by chilhness, fever, and general malaise. 
These symptoms are absent in kerion. An abscess 
when ripe shows fluctuation and contains pus. Kerion 
is boggy to the feel and generally does not contain pus. 
There is no discharge from an abscess unless it has 



KERION. '}n 

been opened either naturally or by the knife, and then 
it gives exit to pus. Kerion pours out a n^ucoid secre- 
tion from numerous foramina. In the hairs pulled 
from over an abscess the trichophyton fungus is want • 
ing. In the hairs pulled from a kerion the fungus is 
usually present, or it wiU be found in hairs from other 
parts of the head. 

The other diseases mentioned above should not be 
confounded with kerion. . A papilloma is non-inflam- 
matory, exceedingly chronic, firm to the touch, and 
has no discharge. A gumma is usually accompanied by 
other signs of syphilis, and tends to break down and 
ulcerate. A sebaceous cyst is slow in its growth; the 
skin over it is normal; it shows no great tendency to 
break down, and if opened it gives vent to a fetid, 
cheesy mass. A fatty tumor is a chronic swelling 
freely movable, rather elastic to the touch, and the 
skin over it is normal. 

Prognosis. — The disease is curnble, although some- 
times with difficulty. The chief thing to be feared is 
the occurrence of permanent baldness, and this will oc- 
cur in some cases even with the greatest care. 

Treatment. — The first thing to which we should 
give attention is to the thorough epilation of the af- 
fected part. This will sometimes save the hair from 
destruction and prevent baldness. It wiU remove a 
certain amount of the fungus from the scalp, and open 
up the follicles for the escape of the mucoid or sero- 
purulent secretion. 

The subsequent treatment wiU depend upon the 
causation of the case. If it is due to the apphcation of 
an irritant, such irritant must be stopped, and a poul- 
tice, hot water, or some mild emollient dressing ap- 
plied. Mild antiphlogistic remedies are also indicated 
in cases complicating eczema and sycosis. But as 
most cases are due to the trichophyton tonsui^ans we 



214 DISEASES OF THE HAlR AND SCALP. 

should at once apply antiparasitics, just as in scabies, 
for instance, we use sulphur, no matter how irritated 
the skin may be. This is advised against by some au- 
thorities, but most are in its favor. The antiparasitics 
mentioned in the chapter on trichophytosis capitis are 
useful in kerion. Of them dilute sulphurous acid; 
solution bichloride of mercury, a grain to the ounce; 
hyposulphite of soda, one or two drachms to the ounce 
of water; carbolic acid, twenty to thirty grains to the 
ounce of v^ater, are perhaps the best. These, joined to 
epilation, will generally result in a speedy cure. 



CHAPTER XIV. 

TRICHOPHYTOSIS BARB^. 

Synonyms. — Tinea sycosis; sycosis parasitica, seu 
parasitaria, seu contagiosa, seu menti; Tinea barbae; 
Trichomykosis barbae (Auspitz) ; Dermatomykosis bar- 
bae nodosa; Mentagra; Herpes tonsurans barbae; Tricho- 
phytie sycosique, sycosis parasitaire (Fr.); Teigne- 
mentagra, (Bazin); Parasitische Bartfinne, (Grer); Par- 
asitic mentagra, Ringworm of the beard, barber's itch 
(Eng.); Sicosi parasitaria (It.). 

Definition. — A contagious parasitic disease of the 
hair of the face and neck, caused by the trichophyton 
tonsurans, which invades the hair follicles, disinte- 
grates the hair, sets up a peri-foUiculitis, with inflam- 
mation of the skin and subcutaneous tissues, and gives 
rise to the formation of pustules, tubercles and nodular 
swellings. It runs a chronic course, is rebellious to 
treatment, and may cause permanent baldness. 

Symptoms. — This is the barber's itch proper, and 
presents different appearances in accordance w^ith the 
depth to which the parasite has penetrated and the 
amount of irritation it causes. It begins as an ordin- 
ary ringworm of the body, a reddish more or less circu- 
lar scaly patch, appearing on the bearded portion of 
the face, which is either scarcely raised above the 
surface of the skin or has its circumference markedly 
raised, and, it may be, vesicular or pustular, while its 
centre is scaly. In some cases, under appropriate 
treatment, the process may go no further; and some- 
times it stops here spontaneously. 



^16 



DISEASES OF THE HAIR AND SCALP. 



In most untreated cases the parasite penetrates the 
hair-follicles, sets up a folliculitis, and peri-folhcuhtis, 
and more or less inflammation of the skin and subcu- 
taneous tissues, giving rise to the formation of pustules, 
papules, tubercles, nodular swellings, and, rarely, ab- 
scesses. According to Behrend (33) it takes about four- 
teen days for the fungus to penetrate the deeper parts 
of the skin. The hair is early affected hke as in the 




Trichophytosis Barbae. 

other forms of ringworm, becoming dry, brittle, 
twisted, and broken off. Over the tubercles and 
nodules the hair may be extracted with the greatest 
ease and without pain to the patient, and it may fall 
spontaneously. The hair roots may be dry, or they 
may be swollen and boggy. 

A characteristic case of the disease presents the 
following features: Upon the chin, neck, and sub- 
maxillary regions, we find a number of tubercles and 



TRICHOPHYTOSIS BARB^. 217 

nodules, varying in size from a split pea to a half cherry. 
These are irregularly shaped, for the most part rounded; 
are prominently raised above the surface of the skin, 
it may be to the height of half an inch; and show a 
marked tendency to group in segments of circles and 
to form patches. There may be one group of nodules 
or there may be half-a-dozen or more. The nodules 
themselves have a congested, purplish look. They are 
either hard and scaly, or they discharge a thick sticky 
fluid from niany follicular openings, or they suppurate. 
The hair over them is broken or stubbed, or it has 
fallen out so that the affected parts are more or less 
bald. The skin between the separate groups is usually 
unaffected, as also may be the case between the indi- 
vidual nodules. But very often the skin over the 
patches is reddened and crusted, and there are a num- 
ber of pustules about the hairs at their exit from their 
follicles. In some cases the amount of pustulation is 
so great that the appearances are very like those found 
in sycosis, and when the crusts are removed the 
affected part presents that moist, raw surface, studded 
with numerous points discharging a glutinous material, 
which suggested the name of (toxov^ a fig. 

Subjective symptoms may be wanting; commonly 
some itching and burning are experienced; sometimes, 
if the inflammation runs high, there will be more or 
less pain, and even some constitutional disturbance in 
the form of chiUs, slight fever and loss of appetite. In 
the vast majority of cases, the patients are more trou- 
bled by the unsightliness of the disease than by any 
physical discomfort. 

The disease commonly affects the chin, neck, and sub- 
maxillary regions. In most cases the upper parts of 
the cheeks are spared, and the upper lip is very rarely 
invaded even in the worst cases. The malady may 
be limited to a single patch, or to one side of the face, 



218 DISEASES OF THE HAIR AND SCALP. 

or may involve the whole face. It is very chronic in 
its course v^hen it once becomes deep-seated. At 
times it may pass over from the hairy to non-hairy 
contiguous parts. 

Etiology. — The trichophj^ton fungus is solely re- 
sponsible for this disease. As it affects the bearded 
portion of the face, men are naturally its victims. It 
is most frequently met w^ith in men of early and mid- 
dle manhood, say from the twentieth to the forty-fifth 
year. The same idiosyncrasy is shown in the suscep- 
tibihty to this as to other forms of ringworm, not every 
man being capable of taking it. Hyde (18) has met 
with it more often in men with light hair and eyes, and 
light brown, reddish or sandy beard. It occurs most 
often among those who shave, and especially those who 
are shaved by barbers. AU classes are attacked by it, 
but it is more common amongst the poor. 

The barber's damp towels, and, may be, his fingers, 
are the most active agents in spreading the disease. 
The shaving brush and razor may convey the fungus, 
though if the water used in shaving is hot, the danger 
is reduced. The razor strop and mug may be mediate 
carriers of infection. The disease may also be acquired 
directly from animals, from cases occurring on other 
individuals, or may be conveyed from other parts of 
the body to the beard. The health of the person has 
no influence upon the disease. 

Trichophytosis barbae is not very common. In 
Boston, White met with it thirty-eight times in 5,000 
cases. In New York, Bulkley had twenty-four cases 
in 8,000. In Glasgow, Anderson saw it but eighteen 
times in 10,000 cases. It is said by Duhring (10) to 
be more common in France, and rare in Vienna. In 
Germany it is quite common, because, as McCall 
Anderson (504) says, "the men there kiss each other, 
and go daily to be shaved," 



TRICHOPHYTOSIS BARB^. 219 

Pathology. — We need not say anything here about 
the appearances of the fungus in the hair and scales, 
as they are the same as in ringworm of the scalp. Eob- 
INSON, (33) has found it in the matrix of the hair and 
between the hair-sheaths. If there is much suppura- 
tion it will destroy the fungus, and none may be found 
in many hairs examined. There is, as a rule, more 
mycelia in the hairs of ringworm of the beard than in 
the same disease of the scalp. At times little, round, 
ghstening bodies are seen in the hairs, in their frayed- 
out ends, and in the remains of the root-sheath, which 
are regarded by Lang (520) as the product of disorgani- 
zation, but not of the fungus. He affirms that the 
proper fungus remnants are cubical, large, glistening 
masses, either simple or forked. It is curious to note 
that before the identity of the parasite of tinea sycosis 
with that of the trichophyton tonsurans was proven, 
it was called the microsporon mentographytes. 

The severity of the symptoms varies with the 
amount and seat of the fungus, and the manner in 
which the tissues react to it as a foreign body, which is 
somewhat a matter of idiosyncrasy. That tubercles 
and nodular swellings are found here and not in the 
same disease as it occurs upon the scalp, is due to the 
amount and looseness of the subcutaneous connective 
tissue. Lang (520) believes that their presence is ac- 
counted for by the inflammation and suppuration of 
the sebaceous glands, which, in the bearded portion 
of the face, lie in very loose connective tissue, and are 
freely supplied with blood-vessels which anastomose 
around them. Tilbury Fox (12) has drawn attention 
to the appearances of trichorrexis nodosa that the hair 
sometimes presents in this disease. This, however, is 
not peculiar to trichophytosis barbae. 

Diagnosis. — The differential diagnosis is, mainly, 
between trichophytosis barbae, and sycosis and pustular 



220 DISEASES OF THE HAIR AND SCALP. 

eczema. Sometimes a large papular or tubercular 
syphilide, au indurated acne, or an epithelioma will 
need to be differentiated. If the characteristics of 
the disease as akeady given are borne in mind, there 
should be little difficulty in making a diagnosis. The 
finding of the fungus in the hair is decisive against 
any of the diseases mentioned above. 

Sycosis affects all parts of the face, notably the 
upper lip, and is entirely devoid of nodular s^\^elhngs. 
Trichophytosis barbae affects by preference the chin 
and submaxillary regions, spares the upper lip as a 
rule, and has large tubercles and nodules which tend 
to group. Sycosis is an active inflammation, and pre- 
sents many pustules pierced by hairs. Trichophytosis 
barbae is a more sluggish inflammation, and presents 
few if any pustules. The hair in sycosis is only 
affected secondarily, and is firmly planted in the skin, 
giving rise to j)ain on extraction. In trichophytosis 
barbae it is primarily affected, split, twisted, broken, 
and is readily extracted without pain. In sycosis there 
is no fungus; in trichoph^^tosis it is often abundantly 
present. Sycosis relapses when ap]3arently cured, and 
often seems to get better and worse with the condition 
of the patient's health. Trichophytosis barbae is not 
so prone to relapse, and is not influenced by the condi- 
tion of the patient's health. 

Eczema barbce is an active inflammation of the s 
of the bearded portion of the face; tinea barbce is a . 
inflammation of the hair-folhcles. Eczema develops 
rapidly; involves large portions of the bearded face, 
or aU of it; is devoid of nodular swelhngs; and pre- 
sents a large amount of crusting. Tinea barbae is 
gradual in its advance, affects the chin and submaxil- 
lary regions, spares the skin between the tubercles, 
nodules, and groups of the same, and, as a rule, is not 
crusted. In eczema the hairs are firmly fixed and 



TRICHOPHYTOSIS BARB^. 22 1 

free of disease; in tinea barbae they are evidently 
diseased, easily extracted, and often wanting. Eczema 
is accomj)anied with far more itching and burning 
than is tinea barbae, and is not contagions. 

The large papular or tubercular sypliilides tend to 
group in circles or segments of circles, as do the lesions 
of trichophytosis barbae. Bub there is generally no 
more than one group of lesions in syphilis; it has a 
characteristic color, and a different history; other evi- 
dence of syphilis may be found, and the lesions tend 
to ulcerate. 

Acne indiirata occurs not only on the hairy but also 
on the non- hairy parts of the face; does not involve 
the hair; and if the nodules, which here are cutaneous 
abscesses, are opened, they give vent to a large amount 
of purulent sebaceous matter. A parasite is wanting. 

Epithelioma should hardly be mistaken for tricho- 
phytosis barbae. It occurs in the form of a circum- 
scribed lesion with waxy margins over which course 
fine blood-vessels. The whole history of its origin 
and progress is different from what pertains to tinea 
barbae, and when the almost inevitable ulceration takes 
place all doubt as to its nature vanishes. 

The superficial form of tinea barbce presents the 
same appearances and has the same symptoms as met 
with in tinea corporis, viz. : a superficial, more or less 
circular scaly patch, with a vesicular or pustular ad- 
vancing edge. 

Treatment. — The treatment of trichophytosis barbae 
is prophylactic and curative. Prophylaxis consists in 
not being shaved by a barber, or, better, in not shav- 
ing at all, as the disease rarely affects those who do not 
shave. If you go to a barber's shop, owning your 
own brush, cup, and razor will not save you. You do 
not know that you can always trust your bai'ber not 
to use your .^iiparatus on other men's faces, Then, 



222 DISEASES OF THE HAIR AND SCALP. 

too, as has been said, the damp towels, the razor strop, 
and perhaps the barber's fingers, may convey the con- 
tagion. If you do not own your own utensils, of 
course, your chances are all the worse. Above all 
things, the cheaper class of barber's shops are to be 
avoided. 

The curative treatment follows very much the same 
line as given in the two preceding chapters. In the 
early stage, and before the hair- follicles have become 
involved, we can often succeed in stopping the pro- 
gress of the disease by painting the affected part with 
a solution of four or five grains of the bichloride of 
mercury to the ounce of alcohol, to which may be 
added a httle glycerine. This is to be painted on 
twice a day with a cotton swab, a fresh one being used 
for each application. Ihle (515) extols resorcin for 
this stage, exhibited in the following paste: 

Pure resorcin, .... 10. 
White vasehne, .... 50. 
Oxide of zinc. 
Starch, aa 25. 

M 

Apply two or three times a day. 

Painting with the tincture of iodine; the apphcation 
of a chrysarobin pigment, (Chrysarobin 10 per cent, in 
flexible collodion); the various mercurial ointments, are 
all good at this stage. When the hair -follicles have 
been invaded, and tubercles formed, a more active 
treatment must be instituted. Epilation now forms 
an essential part of the treatment. The hair is to be 
puUed not only from over the lesions but also for a^ 
small zone about them. Shaving is also to be prac- 
tised, and it is often well to shave one day and epilatej 
the second or third day, according to the rapidity with] 
TV'hich the hair grows. Ihle clairns that by usin^ hi^ 



TRICHOPHYTOSIS BARB^. 223 

paste, as given above, epilation is not necessary, as 
the diseased hairs come out of themselves. He advises 
cutting of the beard and applying the paste two or 
three times a day, its strength being gradually in- 
creased if well borne, up to twenty -five or fifty per 
cent. When pustulation and inflammation begin to 
lessen, the strength of the resorcin is to be reduced. 
When apparently well^ a three per cent, ointment is 
to be continued for some time. 

The rule, however, is to epilate and shave, and to 
apply your parasiticide after either, and re-apply it two 
or three times a day. A bichloride of mercury, solu- 
tion, gr. i to ij, in water or alcohol S j; a solution of 
hyposulphite of soda 3 j, to water i j ; dilute sulphurous 
acid; a two to four per cent, carbolized oil; a ^ve to 
ten per cent salicylated oil (castor oil preferred); a five 
to ten per cent, oleate of mercury; a saturated solution 
of boracic acid; tincture of iodine; an ointment of 
sulphur, or of yellow sulphate of mercury, thymol, 
ornapthol; these are all good parasitics. Tilbury Fox 
(512) advised the use of an ointment composed of 

Hydrarg. Ammoniate. 
Hydrarg. oxidat. nitrici, 
Acidi carbolici, 
M Adepis, 

Hardy (514) directs that the part be epilated and 
then bathed with a sublimate solution 1 in 500. The 
next day an ointment composed of 

Hydrarg. sulph. fiavae, . . 2 parts. 
Pulv. camphoris, . . 1 part. 

M Adepis, .... 27 parts. 



gr.v 


= 


.3 


gr.v 


= 


.3 


gr.x 


= 


.6 


ij 


= 


30. 



or of 



Sulphur, sublimat. . . 2 parts. 

M Adepis, , , , , 28 '^ 



224 DISEASES OF THE HAIR AND SCALP. 

is to be constantly worn. When there is much in- 
flammation he uses emoUient dressings until it has 
subsided, and then employs the above plan. Neumann 
(27) advises green soap frictions, the opening of pus- 
tules and multiple scarifications of the patches. When 
there is deep infiltration he uses a plaster composed 
of equal parts of mercurial and diachylon plaster, with 
enough olive oil to make it soft. 

Behrend (3) speaks highly of scraping the patch or 
patches with the sharp spoon. Gamberini (59) paints the 
affected parts with a solution of oil of juniper in tinct- 
ure of iodine. In the Algemein. Wien. Med. Zeit. 
(506) for 1884, it is recommended to apply after epila- 
tion and every morning and evening, the following: 

Hydrarg. bichlor 01.-02 

Sapo-viridis, 
M 01. cade, . . . aa 5. 

Epilating, shaving, and the careful use of parasiticides 
will effect a cure. 

Prognosis. — When left to itself the disease is very 
chronic. It may end spontaneously, though with per- 
manent loss of hair. If properly treated it is perfectly 
curable, and leaves no traces. The prognosis of ring- 
w^orm of the beard is indeed the same as that of the 
head, though it is somewhat easier to cure. 



CHAPTEE XT. 

FAVUS. 

Derivation: Favus (Lat.) a honeycomb. 

Synonyms. — Porrigo lupinosa (Willan;) Porrigo 
favosa, Porrigo lavalis; Porrigo scutalata (Lebert); 
Porrigophyta (Gruby); Tinea favosa; Tinea vera; 
Tinea ficosa (Pare); Tinea lupinosa (Gui de Chaliac; 
Tinea maligna; Trichomykosis favosa (Auspitz); Der- 
matomycosis favosa; Kerion; Teigne faveuse (Ali- 
bert); Teigne du pauvre; Crusted or honeycomb 
ringworm, scall head, true porrigo (Eng.); Erbgrind 
(Ger.); Kopskurv. (Slav). 

Definition. — A contagious vegetable parasitic dis- 
ease due to the invasion of the hairy scalp by the 
Achorion Schoenleinii. It is characterised by the pres- 
ence of discrete or confluent, circular, pale, sulphur- 
yellow cupped crusts perforated by hair, or by asbestos- 
like masses of grayish crusts; by loss of hair producing 
irregularly shaped, disseminated, red baid patches; by 
running a chronic course; and by causing permanent 
atrophy of the scalp. 

Symptoms. — Favus begins either as one or more 
scaly erythematous spots, as minute yellowish puncta 
or as a group of vesicles smaller than those met with 
in ringworm. But though this is the mode of origin, 
the physician seldom sees a case in that stage, except- 
ing as he may find new points developing upon a scalp 
already bearing the disease in a pronounced form. 
As usually met with, we find that the hair is dry and 
lustreless, and in places it has fallen out, leaving irregu- 
larly shaped bald patches, of all sizes, and of rather 

brilliant red color. Upon separating the hairs, and 
15 



£^6 



DISEASES OF THE HaIR AND SCALP. 



examining the scalp more closely, we will find both 
upon the bald, patches and upon parts of the scalp 
covered with hair, Httle, sulphur-yellow, cup or saucer- 
shaped crusts, with raised or rounded edges, out of the 
middle of which one or several hairs will be growing. 
Besides these cups there will be more or less scaling, 
and if the disease is of some age, thick, mortar-like 




Favus. 

crusts of grayish color. If we approach near enough 
to the patient, we will appreciate a peculiar odor from 
the scalp. 

The characteristic features of favus are: 1. Sulphur- 
yellow cupped crusts. 2. Baldness occurring in irregu- 
lar patches. 3. Dryness and loss of lustre of the hair. 
4. A peculiar odor. In a typical case aU these symp- 
toms are present. Let us examine each one by itself. 

1. The cupped crusts. These are present very 
shortly after the commencement of the disease, and 



i 



are to be found at some period in all cases. They are 
situated about the hair-iollicles. At their beginning 
they are small, about the size of a pin head, but grow- 
ing rapidly they attain the size of a split pea. These 
are called favi or scutula. Though usually described 
as cup-shaped, they seem to me to be more like a sau- 
cer in form. Their edges are rounded and several 
lines in thickness. The depression in their centres is 
well marked. They are round and concavo-convex, 
the concavity looking upwards. At first they are 
covered with a thin layer of epidermis, but later the 
edges are free. When they are picked off from the 
scalp, which can readily be done, they leave a moist 
depression, which soon fills up. Or the scalp, under 
them, may be dry, red and atrophied; or it may be 
pustular. The color of the crust is pale or sulphur 
yellow : if of long standing it may become a dirty or 
greenish yellow from extraneous matter. The surface 
of the crust is uneven, and its centre is pierced by one 
or more hairs. These crusts occur discretely and dis- 
seminated; sometimes in groups. They are firm in 
consistence, and when crushed between the fingers 
they impart a feeling of crumbhng, somewhat like 
mortar. Around them is a slight zone of redness. 

In old cases these cupped crusts may not be present. 
We will then find thick mortar or asbestos -like grayish 
crumbly masses of scales, or perhaps these may be 
greenish yellow as if they were composed of dried pus. 
But if they are cleared off and the scalp left to itself, 
the scutula will again develop. 

2. Baldness occurring in irregular patches. This is 
almost as characteristic of favus as are the scutula. 
The patches are of all shapes, though they show little 
inclination to become round or oval. There may be 
only one or two bald spots, or the whole scalp may be 
so denuded of hair that the condition may be better de- 



^f^S DISEASES OF THE HAIR AND SCAJLP. 

scribed as a bald scalp with irregularly shaped and sized 
patches of hair. In the active stage of the disease the 
bald patches are covered more or less with scutula and 
crusts, and here and there will be sohtary hairs, or 
httle tufts of hair. Their color is an inflamniatory 
red in the active stage, Vv^hich pales with time. They 
have a cicatricial look, due to the atrophy which 
always takes place. They are wanting in glands and 
hair-folhcles, and are permanent. 

3. Dryness and loss of lustre of the hair are always 
present. The hair, unhke what obtains in ringworm, 
is affected secondarily, and grows, though with impaired 
vigor, for some time after the scutula have formed. 
Eventually, the growth of the hair is -interfered with 
by the general atrophy of the skin, and by invasion of 
their roots and shafts by the parasite. They then be- 
come dry and brittle and, may be, spht longitudinally 
and fall out of themselves, or on account of traction 
from brushing, scratching, and the like. They are 
easily pulled out when their roots are invaded and do 
not break so readily as in ringworm. 

4. The odor is always present in a well-marked un- 
treated case, and has been variously described as 
''menagerie like," or "mousey" or, like the urine of 
cats, or as ' ' stale straw. ' ' In doubtful cases it may 
be an aid in diagnosis as it is quite unlike the smell of 
pustular eczema or syphilis. 

Itching is the only subjective symptom. The disease 
may be comphcated by eczema, syphilis, pediculosis, 
or any other disease of the scalp, and these may some- 
what alter the clinical ajDiDearances. In this way we 
may have a decidedly pustular element added. As in 
other inflammatory diseases of the scalp, enlargement 
of the glands of the neck are quite commonly encoun- 
tered. Kaposi (19) says, that in the course of such 
fevers as typhus, variola, and pneumonia, the favus 



FAVUS. 2^9 

growth is checked only to begin again in convales- 
ence. 

Various names have been applied to designate the 
different clinical pictures presented by favus. Thus 
we have: F. discretus, when confined to one spot; F. 
confertus, when it extends over large surfaces; F. 
scutiformis, when in moderate oval patches; F. cohoer- 
ens, when a number of cups join: F. gran ulatus, when 
in mortar hke masses; F. urceolaris or dispersus, when 
disseminated. Charpy (539) has described one form 
in which the crusts are millet seed sized and dissemi- 
nated throughout the hair, to which he has given the 
name of F. miliaire. 

Etiology. — The disease is due to the implantation 
and growth of the achorion Schoenleinii primarily in 
the scalp and secondarily in the hair. This vegetable 
fungus was first described by Schonlein in 1839, in 
Mueller's Archiv filr Anatomie und Physiologie. In 
1841, Gruby also described it, and at the time he was 
unaware of the discovery of Schonlein. 

Favus is highly contagious, though not so much so 
as is ringworm. Its victims are mostly children of 
the poorer classes who neglect the most ordinary rules 
of hygiene, such as Hungarians, Poles and other for- 
eigners. It is exceedingly rare to see favus of the 
scalp in our own people, and in this country it is one 
of the rarer skin diseases; the statistics of the Ameri- 
can Dermatological Association in 1885 record only 32 
cases in 16,863. But while it is not so contagious as 
is ringworm, it is more persistent. While ringworm 
tends to spontaneous recovery as puberty is reached, 
and it is exceedingly uncommon to see it in the adult, 
favus persists indefinitely. I have seen it in a woman 
well on in her twenties, and in a man in his thirties, 
not only in the form of permanent bald spots, but with 
scutula and asbestos crusts. The disease may be ac- 



230 iDISEASES OF THE HAIR ANB SCALP. 

quired either mediately or inunediately ; that is, directly 
from another individual suffering with the disease, or 
by wearing the cap or using the brush or comb of a 
favus patient. Hebra and Kaposi (15) say it is more 
common in males than females. Bergeron (45) found 
that it was more prevalent in the country than in the 
city. It does not affect all individuals, but seems to 
require some undefined peculiarity of soil for its lodge- 
ment and growth. How great a role the strumous or 
other diathesis plays in etiology it is difficult to deter- 
mine. Many of tlie cliildren with favus are strumous, 
but that is a very common condition in this class of 
children. Aubert (533) asserts that the disease is 
prone to foUow injuries to the scalp, and Kaposi (19) 
says that the spores must land upon macerated epider- 
mis or in a hair-folhcle, and he there for some httle 
time before they wiU grow. 

Animals are subject to favus, and from them it may 
be acquired by man. It occurs in mice, rabbits, dogs, 
fowls and cats. When occurring in the mouse the 
pressure of the fungus may cause not only atrophy of 
the skin but also of the bones of the skull, and kiU the 
animal by exposure of the brain, the bones of the skull 
being completely destroyed. 

Pathology. — A.E. Robinson (33), who has carefully 
investigated the parasitic diseases of the skin, thus 
describes the appearances of favus: '' The mass (favus 
cup) is composed almost wholly of the luxuriant vege- 
table growth in various stages of development. The 
most apparent is the mycehum in the shape of flat, 
narrow threads branching and inosculating with one 
another in various directions. Their diameter is about 
the TOT part of a]i inch, and their color is pale-gray, 
sometimes tinged with green. When in a state of 
fractification these tubes are divided into numerous 
small compartments by dehcate cross lines, sometimes 



J 



FAVtJS. 23 1 

with constrictions, giving a chain-like appearance; 
and in each compartment are seen young spores in 
various stages of growth. The spores or conidia are 
present in abundance amid the meshes of the apparent 
growth. They are very small, of varying form, round, 
oval, flask or dumb-bell shaped, and of a pale greenish 
color. Intermediate forms between the spores and 
mycelia are always present, and fungoid growths of 
various kinds, as well as micrococci and bacteria, are 
often accidentally in the field of view. 

'' The parasite first obtains a lodgement in the fun- 
nel- shaped depression in the epidermis, through which 
the hair- shaft emerges upon the surface. It grows 
luxuriantly in the upper part of the hair-sac, and in- 
sinuates itseK on all sides between the superficial layers 
of the epidermis. When it reaches a short distance 
on all sides of the folhcle-mouth, it breaks the looser 
layers and appears on the surface, giving us the 
famihar cup-shaped bodies. It also invades the hair- 
shaft itself, though not to the extent that the tricho- 
phyton does. It penetrates between the cellular layers 
of the root -sheath, and multiplies in the cortical sub- 
stance of the hair. The nutrition of the hair is inter- 
fered with by the mechanical pressure of the growth 
upon the papillse. The hair falls out, and eventually, 
in many cases, the papilla atrophies, and a new growth 
becomes impossible. In cases of any standing the 
parasite may be demonstrated not only in the cortical, 
but in the medullary substance of the hair. Splitting 
of the hair may occur, as in tinea tonsurans, but as a 
usual thing the hair falls out before that occurs. 

'^ In the skin itself tlie parasite usually confines itself 
to the upper corneous cells, and does not extend to the 
living tissues. In cases where the surface is covered 
by irregular, mortar- like masses of parasite, the entire 



232 DISEASES OF THE HAIR AND SCALP. 

upper layer of the epidermis wiR be found infiltrated 
with the achorion. 

' ' The coriuni itself is usually in a state of chronic 
inflammation, and suppuration, which may be quite 
abundant, often occurs under the crusts. Even where 
no pus is found, the pressure of the parasite causes 
atrophy of the skin, and at last pit -like depressions, or 
more extensive reddened scars are left. When the 
granular structures are entirely destroyed, the achorion 
no longer finds a suitable nidus, and the disease at 
that spot is at an end." 

The fungus of favus does not affect the hairs so 
readily as does that of ringworm. Unna (5Y9) has 
found that the hair is sometimes diseased only in its 
upper one-third, while the inner root -sheath is diseased 
throughout. Sometimes, on the other hand, the hair 
may be diseased throughout and the inner root-sheath 
unaffected. He has found the hair-bulb uniformly free 
from fungus, and the cortex generaUy undiseased till 
to about the upper border of the lower fourth of the 
hair-folhcle. The usual point of entrance of the fun- 
gus into the hair is at that part of the hair follicle 
where the sebaceous glands find entrance, the fungus 
making its way through the cuticle of the hair. From 
the point of the entrance into the hair, the fungus 
grows up and down. The achorion furnishes a cement 
to the corneous cells in which it lives, so that the cor- 
neous layers do not scale off but form cups, and, later, 
mouldy or brittle masses, and the hairs do not break 
up as in trichophytosis. 

The formation of the yellow cup is accounted for in 
several ways. 1. The parasite gains entrance into the 
hair -follicle and grows out in all directions from it as 
a centre. The outer rings are the newest and more 
succulent, while those nearer the hair or point of de- 
parture are the oldest and drier. Hence the latter; 



. FAVUS. 233 

will be depressed by the pressure of the atmosphere. 
2. The epidermic cells in the immediate neighborhood 
of the hair are more firmly attached to the hair than 
are those further away, hence will not so readily give 
way and bow out under the pressure of the parasitic 
growth. 3. EoBiNSON (33) has shown that the peripheral 
portion of the cup consists of a dense collection of my- 
ceha, imbedded in a granular debris, while the central 
portion is composed almost entirely of spores which are 
not very closely packed together. From this it results 
that the peripheral portion of the cup is much firmer 
and more resistant to external pressure than the cen- 
tral part, and does not so readily sink in. 

The objective symptoms of favus are due to the 
growth of the achorion. The skin is atrophied on 
account of the pressure of the growing fungus upon 
the constituents of the skin, as it were, squeezing the 
life out of them. Whether the aclioion Schoenleinii is 
a parasite distinct from the trichophyton fungus is a 
question that is still under discussion. The majority 
of investigators believe that it is, and inoculation ex- 
periments support them in their belief. Grawitz (435) 
has recently inoculated several subjects with pure cul- 
tures of favus and ringworm, and each has produced 
the. disease peculiar to itself alone. Quincke (568) 
has found in his cultures of favus crusts, that at least 
three different fungi are capable of producing the clini- 
cal picture of favus. In each of the examined cases, 
one form was found. The three forms he designates 
only as «, ^, r, fungi. They show marked difference 
under cultivation. As yet Quincke has not been able 
to classify them botanically. 

Diagnosis. — Most cases of favus are easy of diag- 
nosis, their features of sulphur-yellow cupped crusts; 
asbestos-like grayish masses; red, atrophic bald spots; 
^nd peculiar odor, being so well marked. It is to be 



234 DISEASES Oy the I-IAir. AXD SCALP. 

differentiated from ringworm, eczema, seborrhoea 
sicca, psoriasis, lupus erythematosus, and baldness 
arising from various other causes. 

1. From Ringivorm. Eingworm is met with chiefly 
in children, rarely persisting to the age of puberty. 
Favus usually begins in early life, but often continues 
into the period of adult life. Ringworm is indigenous; 
favus is most often an imported disease, and is met 
with in Hungaria^ns, Poles, and other foreign races 
which are uncleanly in their habits. Eingworm occurs 
in the form of circular, circumscribed spots, partially 
denuded of han, and covered with grayish scales in 
moderate amount. It has no cupped crusts, and entire 
baldness is rare except from the results of treatment. 
Favus is more multiform and presents to view either 
discrete or grouped yellow-cupped crusts; or gray 
mortar -like masses of parasitic debris-^ or irregularly 
shaped bald spots scattered through the whole head, 
which a]'e atrophic, devoid of follicles, and either red 
or white in color, according to their age. In some 
cases there wiU be a mixture of all these features. In 
ringworm the hairs look as if nibbled off, and we find 
many " stumps; " in favus stumps are not met with, 
and the hair though dry and cracked is not broken off. 
When we attempt to epilate in ringworm the hair 
breaks and leaves its root behind; in favus the hair 
with its root will come out entire. Eingworm has 
no characteristic odor. In a well-marked case of 
favus the odor of stale straw or mice wiU. be readily 
ai)preciated. In doubtful cases we may often decide 
whether the disease is ringworm or favus by the 
microscope. The conidia of favus are more mani- 
fold in shape than those of ringworm and slightly 
larger. In the hair, in favus, we have chiefly my- 
celia, which sometimes are exceedingly long; while 
in ringworm the conidia are found in greater abun- 



FAVUS. 235 

dance. But it is by no means easy to accurately differ- 
entiate between the two diseases by the microscope 
alone, and we must trust chiefly to the symptoms 
and course of the disease in our diagnosis. 

2. From eczema favus needs to be differentiated when 
it is of long standing and there are no cupped crusts pres- 
ent. Sometimes the scalp of a patient with favus may be 
irritated by treatment to such an extent that it may 
become eczematous ; but this is an accident that need not 
detain us. We would speak here of the diagnosis from 
pustular eczema in a doubtful case. In favus we 
have often a history of contagion, which is not found 
in eczema. Favus is usually confined to the hairy scalp. 
Eczema of the scalp is usually accompanied by eczema 
behind the ears, and quite commonly it extends upon 
the neck and forehead. The grayish, dirty-looking, 
thick, friable crusts of favus are in strong contrast 
with the greenish, tenacious crusts of eczema. On 
removing a favic crust we leave a dry, red surface. 
When an eczematous crust is removed, a moist, ex- 
uding surface is exposed. In favus the hair is dry, 
lustreless, and more or less split longitudinally. In 
eczema the hair is matted together, and may be dry, 
but it is not otherwise altered. Favus causes perma- 
nent bald spots of red and atrophic appearance. Ec- 
zema as a rule does not cause baldness, and never 
gives rise to permanent alopecia. The mousey odor 
of favus is vastly different from the sickening smeU of 
pustular eczema. 

The pustules of a discrete pustular eczema or im- 
petigo are rounded, non-umbilicated, whitish or grayish 
in color, and contain pus. These should not be con- 
founded with the straw-colored or yellow cups of favus, 
which are umbilicated and firm and do not contain 
pus. 

3r From sehorrhaia sicca, Favus affects all part^^ of 



236 DISEASES OF THE HAIR AND SCALP. 

the scalp indifferently and irregularly; seborrhoea is 
most frequently confined to the upper portions of the 
head, and when present to a sufficient degree to require 
differentiation from favus, it will form a continuous 
patch covering the whole top of the head with the hair 
dry and more or less matted. The crust of favus is diy 
and brittle and gritty to the feel: that of seborrhoea 
is friable, but greasy to the fee], and when removed 
leaves a normal or pale skin. Seborrhoea has no char- 
acteristic odor, no cups, and if it causes baldness it 
will be at first a general thinning of the hair, and 
with it the amount of seborrhoea will lessen. The bald- 
ness caused by fa^ois is permanent, and the skm is 
smooth and atropine. 

4. From Psoriasis. Psoriasis does not occiu* upon 
the scalp alone; when found there, other lesions avlU 
be fomid elsewhere on the body. Favus is quite gen- 
erally found on the scalp alone. The crusts of psoriasis 
are scattered about through the whole scalp, are cir- 
cumscribed and discrete, and when removed the skin 
underneath will be found reddened but not ati'ophic. 
Psoriasis presents no lesion like the cupped crust of 
favus, and does not cause permanent baldness. 

5. Lupus erythematosus resembles favus only in 
forming red cicatricial bald areas, which are crusted. 
Its bald patches are really cicatricial, while those of 
favus are atrophic. The cicatrix of lupus is often de- 
forming. Lupus is much slower than favus in its 
course, is generally more limited in its distribution, has 
no cupped crusts, and when crusted the crust is thin 
and adherent, and never forms the thick mortar-like 
masses of favus. 

6. From Alopecia. Alopecia areata presents per- 
fectly bald, smooth, non- scaly, white, circular, cu^- 
cumscribed patches, the skin of which is normal in 
appearance, though it may be somewhat pale and thitt. 



FAVUS. 937 

Its history and course are distinct from what obtains 
in favus. The baldness arising from syphilis, as 
seen in the early stages of the disease, and due to the 
general hydraemia, is more like the baldness arising 
from favus than is any other form of alopecia. But 
the hair in syphilis is less affected than in favus, and 
when it falls it gives the head a ragged appearance, as 
if the hair had been cut off in an irregular manner 
with a pair of dull shears. There are no crusts, and 
there is a history of an initial lesion and a general 
eruption. When the baldness is due to a late ulcerat- 
ing lesion the history will be distinct, and the cicatrix 
well marked. The other forms of baldness will be 
sufficiently distinguished by the history of their onset 
and course, and the absence of all the other characteris- 
tics of favus. 

In doubtful cases the finding of myceha and conidia 
in crusts and hair will positively exclude eczema, 
seborrhoea, psoriasis, lupus, and alopecia. If a case 
presents itself with thick crusts; or, if by reason of 
cleanliness, it has only red, bald patches, and we are 
told that it has lasted for some time and is very scaly, 
we can determine the presence or absence of favus 
by letting the disease f oUow its own course for a time, 
and watching it. Of course aU the crusts that may 
be present must be removed. In the course of two 
or three weeks or less, if the case be one of favus, we 
will notice, at first, httle red spots upon the scalp, and 
later the development of cupped crusts. 

Prognosis. — Though the disease is obstinate to treat- 
ment, still it is perfectly curable when handled with 
intelligence and perseverance. A promise of speedy 
cure should never be given, as it is always a matter of 
months, and sometimes of years. Even after the dis- 
ease is apparently cured, we should have the patient 
present himself for inspection at intervals of (i few 



233 DISEASFS OF THE HAIR AND SCALP. 

weeks during a year. Uniorcuiiately we can do noth- 
ing to remedy the damage done to the scalp in the 
formation of bald patches. These are permanent, 
though they will become less disfiguring by time, as 
the redness gradually fades. 

Treatment. — In the treatment of favus patience and 
method are of more value than any special medica- 
tion. Without perseverance on the part both of phy- 
sician and patient it will be impossible to cure a case. 
Epilation, cleanliness and parasiticides are the means 
at our command for combating the disease. 

The first thing to be done is to clean the scalp of 
all crusts. This is accomplished by keeping the whole 
scalp soaked in oil for a day or two, according to the 
thickness of the crust, and then washing with an 
abundance of soap and water. For an oil we may 
choose either sweet or ohve oil, or oil of sweet almonds, 
and it is useful to add some parasiticide to the oil, 
such as carbohc acid gr. xv ad 3 j ; or salicyhc acid, 
three per cent. Or we may use a poultice to remove 
the crusts, though this is a more disagreeable method. 
When the crusts have been got rid of we must epi- 
late, and prevent the new formation of crusts by 
the use of our chosen parasiticide, and by washing, at 
intervals, with soft soap or the tincture of green soap. 
As a rule it is best to allow the parasiticide to remain 
undisturbed upon the scalp, and not to wash the head 
more than once or twice a week. 

The most important means of cure is epilation, which 
may be accomplished by one of three methods: 1. By 
the pincette or epilating forceps; 2. By Kaposi's (19) 
method; and 3. By the " calotte," or by the epilating 
stick, which is a modification of the calotte. 

The first method, or that of the forceps, is the one 
most commonly employed, and when systematically 
carried out, is thoroughly reliable. Care must be given 



FAVus. 239 

to the selection of the forceps. They should have an 
easy spring and their edges should accurately coapt. 
I prefer to have the blades grooved transversely on 
their inner face, as the hair is more firmly held by a 
roughened than by a smooth blade. Each hair must 
be plucked out from the diseased patch and from a 
little area around it. The operator should begin at 
one portion of the patch and clear off a small part 
every day, each hair whether sound or unsound being 
pulled out by a rapid jerk of the hand in the direction 
in which it grows. The chosen parasiticide should be 
appKed immediately to the part epilated. 

Kaposi's (19) method has for its object the epilation 
of the diseased hairs alone. When the forceps is used, 
both the sound and the unsound hairs are pulled out. 
Of course it is desirable to spare the sound hairs, and 
Kaposi maintains that if little bunches of the hair are 
pulled between the thumb and some firm object, such as 
a straight spatula, held within the grasp of the fingers 
enough traction will be exercised to extract the loos- 
ened and diseased hair, but not enough to disturb the 
healthy and firmly seated hairs. This is Kaposi's 
method, which has given him satisfaction. It is rapid, 
and less painful than any other mode of epilating. 

The ^' calotte,'''^ or pitch-cap, is the most rapid means 
of epilating, but is painful and sometimes dangerous. 
The "calotte" is composed of, 

Vinegar, .... 150 parts. 

"Wheat flour, .... 25 " 

Black pitch, .... 25 " 

White pitch, .... 25 " 



made into a mass and spread on leather. This is ap- 
plied, while soft, to the whole head and when it has set, 
is pulled off suddenly by taking hold of the part over 
the foreheadj and removing it from before backwards, 



240 DISEASES OF THE HAIR AXD SCALP. 

Its use was abandoned on account of some unfortunate 
accidents. Since then various epilating sticks have 
been invented to take its place. One of these much 
used by Bulkley (538) is composed of 

Cerae fiavae, . . 3 iij say 10. 

Laccse in tabuhs, , . 3 iv ^' 15. 

Picis burgundicae, . . 3x '' 35. ' 

Gummi damar, . . iiss '' 40. 

These are made into a mass and cast in sticks from 
half an inch to an inch in diameter and two inches in 
length. One end is heated and apphed with a sort of 
boring movement to the part to be epilated. When 
cold it is removed by a sudden twisting motion. The 
hair will be found sticking to the end, and must be re- 
moved by burning before the stick can be used again. 
Several sticks may be employed at once to a large 
patch. For hospital or dispensary work these epilat- 
ing sticks are serviceable, but are rather harsh for 
private practice. 

Whatever method is used it must be faithfully car- 
ried out. A skilled nurse should be employed for the 
work, and where such is not attainable, the physician 
must make it his duty either to do the epilating him- 
self, or to train some member of the family for the 
work. 

Parasiticides are next in importance to epilation, and 
should be applied after that procedure, not only to the 
part epilated but to the whole scalp; the latter in order 
to prevent the spread of the disease. There are many 
excellent ones from which to choose, such as a half per 
cent, solution of bichloride of mercury in ether or 
alcohol; the oleate of mercury or copper; the essential 
oils; tar; oil of cade; creosote in ethereal or alcoholic 
solution, or in oil; sulphurous acid in full strength; 
qarbohc or sahcyhc acid, 3 to 5 per cent, in oil; the pint- 



ments of the ammoniate or yellow sulphate of mercury; 
and various others. Ointments or solutions of thymol, 
napthol, pyrogallol, or chrysarobin in five to ten per 
cent, strength, are among the newer remedies. Hyde 
(18) quotes Lenzberg as saying that he had never failed 
to cure a case of f avus without epilation by generating 
sulphur fumes, carrying them to the head by means of 
a paper cap, and continuing the fumigation for five or 
ten minutes. 

Sawicki (572) recommends cutting the hair short and 
covering the whole scalp, crusts and all, with a paste 
made out of powdered chalk or gypsum with five oi^ 
ten per cent, of carbolic acid. The paste is to be laid 
on 0.5 cm. thick, and the head bound with a damp 
cloth. In three days the whole is removed, the scalp 
washed with a potash soap, and the dressing reappHed. 
Three or four applications are said by him to effect a 
cure. The oil of naptha has been used from time to 
time, applied morning and night, after washing the 
scalp with soap and water. This often proves irritat- 
ing. Unna (493a) has recently recommended icthyol 
in the form of spray for favus. Ihle (554) cured one 
case in two months by means of a five per cent, resor- 
cin ointment. I have seen as satisfactory results from 
epilation and the use of a three to five per cent, solu- 
tion of salicylic acid in castor oil, kept constantly appli- 
ed, as from any other plan of treatment. This is the 
method in use in Dr. Geo. H. Fox's service in the 
New York Skin and Cancer Hospital. 

The treatment of favus consists then, in 1st. Cleaning 
the scalp; 2nd. Epilating; 3d. Applying a parasiticide. 
These procedures must be repeated again and again, 
and the whole diseased portion of the scalp worked 
over and over, until the hair is apparently growing in 
a healthy manner and the scalp is free from reddish 
points freshly cropping out. Then the scalp should be 
16 



^4^ DISEASES OF THE HAIR AND SCALP. 

left entirely alone for a few weeks. At the end of that 
time it should be inspected, some hairs examined 
under the microscope, and if there is no sign of the dis- 
ease present, the case may be discharged. Even then 
the patient should be examined from month to month 
for some months, to make sure of the durability of the 
cure. 



OHAPTEE XVI. 

PEDICULOSIS CAPITIS. 

Synonyms: — Phthiriasis; Phtheiriasis; Morbus pedic- 
ularis; Pedicularia; Malis pediculi; Pediculosis capil- 
litii; Lousiness (Eng.); Lausesucht (Ger.); Phthiriase, 
ou Maladie pediculaire (Fr.). 

Definition. — A contagious disease of the hairy scalp 
due to its invasion by lice. It is characterized by the 
presence of the lice and their ova upon the scalp and 
hair; by the wounds inflicted by their probosces; by 
pruritus; and by lesions consequent upon scratching. 

Symptoms. — The attention of the patient is first 
drawn to his disease by itching of the scalp, due to the 
irritation produced by the louse in its endeavor to ob- 
tain its nourishment from the skin, which it does by 
inserting its proboscis into the follicles; and by its 
moving about on the scalp and hair. The amount of 
itching varies with the susceptibility of the individual, 
with the number of the lice present, and with the ex- 
tent and duration of the disease. One louse will cause 
as much itching in one individual as a whole army of 
them will give rise to in another. In susceptible indi- 
viduals, and in aggravated cases, the itching may be so 
intense as to cause loss of sleep, and consequent loss of 
health, emaciation, and such constitutional symptoms 
as to constitute a grave disease. The itching always 
induces scratching, and the rubbing and tearing of the 
scalp by the nails gives rise to the lesions of the dis- 
ease. These are either merely excoriations, or isolated 
pustules, or a veritable pustular eczema, varying with 
the individual. People who are in bad hygienic sur- 



2ii DlSBASSS Of fUfi lIAIft AKD scalp. 

roundings, poorly nourished, uncleanly, and of stru- 
mous habit present the most pronounced lesions. 

The part of the scalp most frequently affected is the 
occipital region. The parietal regions stand next in 
order of invasion, but always in conjunction with the 
occipital region. In the vast majority of cases the 
disease is hmited to these localities, but sometimes the 
whole head is affected, and in bedridden, uncleanly in- 
dividuals the head-Uce may be found on the trunk. 

The picture presented by a well-marked case of pedi • 
culosis capitis is the following: On lifting the hair 
from the back of the head a reddened, oozing, excori- 
ated, crusted patch of varying size is uncovered, with 
outlying pustules, and cutaneous abscesses or furun- 
cles, a veritable pustular eczema of high grade. The 
hair is matted together by the exudation, and myriads 
of Hce will be seen running around amongst it and 
crawling along the hairs. There will be multitudes of 
ghstening white or yellowish ova firmly attached to 
the hair shafts, sometimes quite near the scalp, some- 
times at long distances from it. Over the whole scalp 
we will find isolated pustules, furuncles, excoriations, 
and patches of eczema. The post-cervical glands will 
be enlarged, there will often be patches of eczema be- 
hind the ears and upon the face and neck, and, ac- 
cording to Kaposi (19), pemphigus -like blebs may occur 
upon the face. 

Pediculosis may occur alone or it may complicate 
other diseases of the scalp, such as eczema, favus, and 
trichophytosis 

Etiology. — The head louse is the only cause of the 
disease, and this is always derived from some other 
individual sufferiug with phthiriasis. It used to be 
thought that hce were the product of an eczema or other 
disease of the scalp, but this view is no longer tenable. 
It gained its support from the presence of an eczema 



f^EMctJLoSlS CAPITIS. ^4^ 

in the cases observed. But though eczema does not 
produce Hce, an existing eczema may favor their 
invasion, providing for them a good and convenient 
feeding ground. 

The disease is met with most frequently amongst 
the poor, but the better classes, even those who are 
most cleanly, are not exempt. Thus Bulkley met with 
228 cases of the disease in 8,000 cases of skin diseases, 
of which 7 occurred in private practice. It is more 
frequent than is pediculosis corporis, as Bulkley 'stables 
show. He met with but 147 cases of the latter against 
228 of the former. Children suffer from the disease 
more than adults, and, among adults, women more 
frequently harbor the vermin than do men. Infants 
at the breast are, usually, exempt from the disease; I 
have seen but few cases in them. The reason for the 
exemption of infants is found in the scantiness of their 
hair, and the greater care that is bestowed upon them. 
Women wear their hair long and their skin is more 
tender than is that of men; they therefore form a more 
favorable lodgment for the lice than men do, and are 
more often affected. 

The cause of the lesions of the scalp in phthiriasis 
is the scratching, nature's plan for allaying the itching. 
The swoUen glands are sympathetic with the inflam- 
mation of the scalp; they are commonly met with in 
all inflammatory diseases of the scalp. 

The louse does not bite, as it has neither mouth nor 
mandibles, but simply inserts his haustellum into the 
follicles of the skin and sucks its food from the deeper 
parts. Thus it is improper to speak of louse-bites. 

Pathology. — The pathology of this disease is con- 
cerned mainly with the louse itself. The pathology of 
the lesions of the disease is the same as that of artifi- 
cial eczema of the scalp, or a common traumatic der- 
matitis. 



246 DISEASES OF THE HAIR AND SCALP. 

There are three distinct varieties of hce which infest 
the human body. 1. The pediculus vestimenti sen 
corporis. 2. The pediculus capitis. 3. The pediculus 
pubis. Each has its own 'province out of which it 
rarely passes. 

The body louse resides in the clothing, which it leaves 
only to draw its food from the wearer of the same. 
This genus of louse does not concern us here. The 
pubic louse is found mostly on the pubes, never on the 
scalj), and will be described in the next chapter. We 
have here to do with the head louse alone. The male 
pediculus capitis is from 1 to 2 mm. long (according to 
Neumann (27) it is 3 to 5 mm. long), and from 0.6 to 1 
mm. broad: the female is larger by a few millimetres. 
It is smaller than the body louse, and larger than the 
pubic louse. Its head is triangular in shape; its body 
forms an elongated oval whose outhne is scalloped with 
seven deep notches. It has three pairs of legs, situated 
well forward at the sides of the thorax, and these have 
powerful joints and strong claws. The legs are covered 
sparsely with bristly hairs. Two fine- jointed antennae 
come off from the head. The color of the louse is gray 
with black outlines. The color varies with the race. 
Thus in the Esquimaux it is white, in the Negro 
black, and in the Chinese yellowish brown. The ova or 
" nits " are about one quarter of a line long, are of oval 
or pear-shape, and of gray color. They are found in 
great abundance glued to the hair- shaft, one hair bear- 
ing anywhere from one to four or more, the lower one 
being the youngest. They are first laid by the female 
along the lower part of the hair-shaft, and then are 
carried further away from the scalp by the growing 
hair. They are difficult to remove and are arranged 
along the hair like grapes upon a stem. 

The female is very prolific, laying from fifty to sixty 
eggs. The young hatch out in six days, and within 



PE^DICULOSIS CAiPlTI^. S47' 

seventeen to twenty days are capable of propagating. 
This accounts for the rapidity of spread of the disease, 
one louse being capable of producing 8000 lice in eight 
weeks. 

Diagnosis.— Pediculosis capitis is most apt to be 
mistaken for an eczema of the scalp, and is not infre- 
quently treated with ointments, such as that of the 
oxide of zinc, which only add the element of rancid 
lard to the already disgusting condition present. This 
mistake need never occur if we bear in mind that an 
eczema of the occipital region is due, in an over- 
whelming majority of cases, to Hce. In every such 
case then, look for the vermin, and you will find them 
or their nits, if the case is one of pediculosis. In some 
cases where only itching of the scalp is complained of 
and the patient is very careful of his scalp, we may 
find neither eczema nor lice, but simply some little 
grayish bodies fastened on the hairs. These may be 
epithehal scales or sebaceous masses perforated by 
hairs, a not uncommon condition; or they may be nits. 
The doubt is readily settled by attempting to remove 
them. If they are epithelial or sebaceous particles they 
will be easily removed by brushing. If they are ova 
they will resist the brush, and sometimes the comb, 
and often will require the application of some agent, 
such as acetic acid, to dissolve their connection with 
the hair. 

Prognosis. — The disease is rapidly and completely 
cured by appropriate treatment. 

Treatment. — The promptest, cheapest, and most 
readily obtainable remedy for pediculosis capitis is 
crude petroleum or common kerosene oil. The head 
is to be saturated with this for a day or two, and then 
well washed with an abundance of soap and water. 
This will destroy the lice, but will not prevent the 
hatching out of the ova. These are to be removed by 



Ms DISEASES OF THE HAlB AND SCALP. 

the fine comb, care being taken not to touch the scalp, 
and by pulling the hair through a towel saturated with 
vinegar or dilute acetic acid. By patience all the nits 
may be removed. As a precautionary measure the 
scalp should be well wetted with kerosene for a few 
days, after it is apparently well, to insure the death of 
any louse which may have hatched from a missed nit. 
The objections to this plan are the danger of fire, audits 
unpleasant odor. The first objection may be met by 
cautioning the patient to keep away from the fire; or 
the danger may be reduced by mixing the petroleum 
with some other oil, such as olive oil. The second 
objection is overcome by adding some perfume to the 
oil. But this is only partially effective, and the plan 
with all its excellencies cannot be used in private 
practice. 

It is always preferable to use lotions rather than 
ointments in treating pediculosis capitis. Ointments 
are apt to mat the hair together and to become rancid. 
There are many drugs and chemicals that destroy lice. 
One of the most desirable for use in private practice, 
and in adults, is a solution of bichloride of mercury, two 
or five g]'ains to the ounce of cologne water or bay 
rum, sopped on several times a day. This is poisonous 
and had best not be used on the heads of children, and 
is contraindicated where there is eczema. In children 
a good substitute is carbolic acid, ten, twenty or more 
drops to the ounce of alcohol, to which a httle glycerine 
may be added. Larkspur seed {stapliisagria) can be 
readily obtained, and a strong decoction of it will be 
found a quick and sure destroyer of hce. Instead of the 
decoction the tincture may be employed. Napthol, 
f\Ye per cent, in oil, is another good remedy. The 
essential oils wiU kiU lice. The decoction or tincture 
of cocculus indicus enjoys a reputation of the same 



PEDICULOSIS CAPITIS. 249 

sort. A five or ten per cent, salicylated oil may be 
used. Instead of a lotion we may use an ointment, 
especially where there is considerable irritation of the 
scalp and an artificial eczema. One of the best is that 
of the ammoniate of mercury made with vaseline in 
twenty per cent, strength. Where eczema is present, 
we want to kill the lice first, when it will be an easy 
matter in most cases to cure the eczema. These ecze- 
matous heads with lice will often bear kerosene very 
well. After the vermin has been destroyed by the 
kerosene, the application of oil of cade, one drachm to 
olive oil one ounce, will act admirably upon the eczema 
and at the same time be a parasiticide. 

An ointment of sulphur is efficient, as is also one of 
sabadilla. The latter should not be used upon a sore 
head as it may cause dangerous symptoms of poison- 
ing. All the ointments of mercury will render good 
service. An ointment of tobacco will destroy the 
pediculi, but it is too disagreeable for use except when 
nothing else is available. Chrisma, a derivative of 
petroleum, has been indorsed by Crane as an active 
parasiticide. (587.) 

Instead of ointments some recommend powdering 
the hair with either calomel, pyrethrum roseum 
(Persian insect powder), powdered seeds of wormwood, 
rue, or parsley. But in my judgment ointments and 
powders are all objectionable. If an ointment must 
be used, then it is better to have it made with vaseline 
rather than with lard, as it is less liable to mat the 
hair. In all cases soap and water should be used for 
washing, and this should be done daily, excepting 
where eczema is present, when water is contraindi- 
cated. In all cases the nits are to be removed with the 
greatest care, and we must in] press upon the patient 
or the attendant, that as long as tliQre i§ a single nit^ 



250 DISEASES OF THE HAIR AND SCALP. 

there is danger of a new outbreak. The nits may be 
removed, as ah^eady stated, by means of vinegar, or 
acetic acid, which is the best. To the same end alco- 
hol, and alkahne solutions, as of borax or soda or the 
tincture of green soap, may be used. 



I 



OHAPTEE X\^IL 

PEDICULOSIS PUBIS ET PALPEBRARUM. 

These two diseases are caused by the same species of 
louse, the Phthirius inguinalis, or, as commonly called, 
crab louse. We will first consider, 

PEDICULOSIS PUBIS. 

Symptoms. — ^When the louse has taken up its habita- 
tion upon the pubes it begins to propagate in the same 
energetic way we have learned of in the preceding 
chapter; and to insert its haustellum into the follicles 
of the skin and suck its nourishment therefrom. The 
movements of the lice upon the hair, and the irritation 
caused by their puncturing the skin, give rise to itching, 
which the patient tries to allay by scratching. The 
itching is at times intense, specially at night, but is 
usually not so violent as in pediculosis capitis, though 
it is as persistent. As a rule there is no great amount 
of dermatitis or eczema present, and it is rare to see 
such a picture presented as we constantly meet with in 
pediculosis capitis. This may be accounted for by the 
fact that the pubic region must be scratched for the 
greater part of the time through the clothes, while 
the scalp is readily accessible to the nails. If the lice 
are present in very great number, or the patient's skin 
is very vulnerable, we may have a ^vell-marked eczema. 
The patient usually applies to the physician on account 
of a pruritus of the genital region, and in the majority 
of cases, is not conscious of having lice on him. In all 



252 DISEASES OF THE HAIR AND SCALP. 

cases of itching about the genitals it is imperative to 
make an examination of the parts. If hce are present 
we mil find them as small, flat, translucent, brownish 
or reddish specks close down to the skin and chnging 
to the roots of the hair. Their position is character- 
istic. They usually are found with their heads buried 
in a skin-follicle, their claws firmly fastened about a 
hair, and their hinder parts sticking up in the air. At 
times one may be found moving about upon the hair, 
but they are far less active than the hce which infest 
the head and clothing. Besides the lice, we will find 
their excrement lying amongst the hair-roots in the 
form of minute reddish particles; and their ova upon 
the hair. As has already been said, we may find a well 
marked eczema of the pubic region. This is excep- 
tional. But we constantly see red, punctate macules 
or papules scattered about, which are scratch marks. 
Now and again, but not constantly, we will see dull or 
slaty giuy, or peculiar pale blue macules, varying in 
size from that of a lentil to that of a split pea or larger, 
scattered over the regions infested by the hce, as over 
the pubes, abdomen, and inside of the thighs. These do 
not disappear on pressure; they last for a few days 
and then vanish of themselves. They are known as 
macidce ceridecB or, in French, tdches ombrees. They 
are unaccompanied by any subjective symptoms. 

The pubic louse is more nomadic than any of its 
congeners. While it is most frequently found, as its 
name indicates, upon the pubic region, it is not infre- 
quently met with upon other parts of the body sup- 
plied with hair, as upon the thighs, about the anus, on 
the abdomen, thorax, and arms, in the axillae, occa- 
sionally upon the eye-brows, eyelashes and beard, and 
sometimes on the arms. In all these situations it gives 
rise to the same symptoms as when on the pubes, and 
Tve must be on the watch for it in all cases of pruritus 



PEDICULOSIS PUBIS ET PALPEBRARUM. 253 

in those regions. It is not found on the scalp. Adults 
are the subjects of the disease in the vast majority of 
cases. 

Etiology. — The cause of the disease is the infesting 
of the part with the pubic louse. The infection most 
commonly is effected during sexual intercourse. It is 
also acquired by sleeping with an infected individual or 
in a bed already infected by some one; and by wearing 
infected clothing. It is quite possible for the vermin to 
infest a woman in public conveyances, on account of the 
peculiar make of her clothing. A man's clothing affords 
better protection. Piffard (29a) thinks that it is pos- 
sible to acquire the disease in water-closets. It is much 
rarer than are the other forms of pediculosis. Bulk- 
ley records but 8 cases in 8,000 cases of skin diseases. 
The tables would indicate that it is proportionately 
more common in private practice than are the other 
forms, as of the 8 cases met with, three were in private 
practice and five were in public practice. 

Pathology.— The pathology of this affection is the 
same as that of pediculosis capitis with but two excep- 
tions, and those are the characteristics of the louse, 
and the maculae ceruleae. These alone wiU require 
notice here. 

The Pubic Louse,— synonyms: pediculus pubis sen 
ferox, phthirius inguinalis, morpio, f oralis pediculus; 
morpion (Fr.); die Filzlaus (Ger.); Crabs (Eng.), — 
has a less triangular and more broad laend than the 
other species of louse, and a well-marked neck. Its 
body is heart-shaped, and its eight segments are not 
clearly indicated by notches in its outline, as is the 
case with the head louse. It has three pairs of legs 
which come off from its thorax, of which the anterior 
pair are proportionately delicate, and bear only a small 
claw at their ends. The two other pairs have a stout 
hook-shaped claw. The male is from O-S mm. to 1.0 



254 DISEASES OF THE HAIR AND SCALP. 

mm. long, and from 0.5 mm. to 0.7 mm. wide; and 
the female is from 1.0 mm. to 1.5 mm. larger. The 
female has a triangular-shaped notch at the termina- 
tion of the abdomen. From the head of the louse 
project two fine- jointed antennae. The color of the 
louse is yellowish gray; and it is more or less trans- 
parent. 

Maculse ceruleae have long been known, but until 
very recent times their significance has been misunder- 
stood, and they have been considered as symptomatic 
of grave fevers, such as typhus fever. 

MouRSON (591) was the first, in 1878, to draw atten- 
tion to the connection between these spots and the 
presence of hce. ' He showed that while everyone who 
has pediculosis pubis does not have the maculae, yet 
everyone upon whom the maculae are found has the 
pediculi, or has had them shortly before presenting for 
examination. They were found more commonly in 
those who had fine skins and did not wash often. 
They are further proved to be due to the hce by the 
fact that if only one axilla was affected with hce, 
they would be found in that axilla alone, the other 
being free. Most of the cases have been found in 
patients suffering from some debilitating disease, and 
their great rarity, — Gibier (589) failed to find a single 
case in two hundred subjects of pediculosis,— would in- 
dicate that some predisposition on the part of the skin 
is a requisite for their formation. The causal connec- 
tion between the pediculi and the maculaB having been 
established, it next remained to determine how they 
were produced. Duguet (588), in 1880, obtained the 
same appearances by pricking the skin with a lancet 
point charged with a paste made by rubbing up the 
bodies of twenty-five lice. But he could produce the 
maculae only in individuals already bearing them; an- 
other nidication of the part idiosyncracy plays in the 



PEDICULOSIS PUBIS ET PALPEBRARUM. 255 

disease. He believes that the maculae are caused by 
the emptying of the contents of the salivary glands of 
the louse beneath the epidermis of the human, uncon- 
nected with any further alterations in the skin. These 
spots spontaneously disappear in about ten days. 

Diagnosis. — The detection of the louse or its nits 
will at once give the diagnosis. It is for us only to 
look for the evidence of pediculi in every case of pruri- 
tus cutaneous, especially when such pruritus is limited 
to the pubic or axillary regions. We should suspect 
and carefully look for lice in all cases of eczema limited 
to the pubis, and even in eczema of the genitals and 
thighs. The pediculus pubis is less easy of detection 
than are the other species of louse on account of its 
small size, light color, translucency, greater quiescence, 
and more or less perpendicular position as it lies deep 
down among the hair-roots. Still if one is but alive to 
the possibility of the vermin being present, he will 
have no difficulty in detecting them when present. 

It is important to determine whether we must deal 
with the pediculus vestimentorum, the so-called body 
louse, or with the pubic louse, as the two species of 
louse demand different treatment. The body louse in- 
habits the clothes alone, and if we search carefully we 
will find either the lice crawling about the clothing or 
will see its eggs deposited in groups along the seams of 
the clothing. The pubic louse dwells upon the hairy 
skin alone, and neither it nor its egg is to be found in 
the clothing. The scratch marks of pediculosis vesti- 
mentorum are found over the shoulders posteriorly, 
about the waist, and along the outer side of the limbs 
where the seams of the clothing come. The long 
parallel scratch marks over the shoulders are pathog- 
nomonic of this form of lice. The scratch marks of 
pediculosis pubis are limited more to hairy parts, and 
therefore are seen more commonly on the anterior face 



256 DISEASES OF THE HAIR AND SCALP. 

of the trunk, and in the axillae. Maculae cerulese are 
met with in this form alone. 

Prognosis. — There will be no difficulty in curing the 
disease if we have once made the diagnosis. 

Treatment. — The quickest and neatest method of 
treatment, when the patient will allow of it, is to 
shave the affected parts. By this means we at once 
destroy the hce, nor need we wait until any comph- 
cating eczema is cured. One of the most frequently 
employed remedies is mercurial ointment. It is effica- 
cious, but very often proves irritating and sets up a 
pustular eczema. A lotion of the bichloride of mer- 
cury is better. If there is much excoriation mercurials 
are to be avoided. Any of the remedies used in pedi- 
culosis capitis will be useful here, and need not now 
be detailed. Chloroform may be used to destroy the 
lice where the skin is uninjured, using the plan pro- 
posed by Hamal (590) in 1857, namely, after washing 
the part with soap and water, and then with clear 
water, and drying, pour chloroform on drop by drop and 
rub in. Then cover with a folded handkerchief for a 
half hour, and wash again to remove the debris of 
pediculi. As the chloroform is irritating it is advisa- 
ble to protect the skin of neighboring parts with pow- 
der. Ether will act in the same way as the chloro- 
form. Hot baths with the free use of soap, and sub- 
sequent bathing with carboHzed water, is a good plan 
of treatment for a generalized pediculosis caused by 
the pubic louse, care being taken to get rid of the ova. 

Mourson caused the maculae ceruleae to disappear 
promptly with a solution of hypochlorite of soda. 

Pediculosis Palpebrarum is a very rare form of 
pediculosis, which occurs most frequently in children. 
It is caused by the pubic louse and is communicated in 
some cases from the beard of a man in the act of 
fondling a child. As a rule there is but little itching in 



PEDICULOSIS PUBIS ET PALPEBRARUM. ^SiT 

this form of pediciilosis, though there is enough to 
cause the patient to rub the eyehds. The irritation by 
the Hce and by the rubbing gives rise to redness of the 
lids and even eczema. Usually the eyelids will be 
found reddened, crusted, and scaly, and sometimes 
some of the eyelashes are broken off. Close examina- 
tion will show the lice either at the roots of the eye- 
lashes in the characteristic position, or wandering 
about, and the eyelashes will have ova upon them. 
Minute reddish specks of excrement are to be seen on 
the edge of the lids, especially the lower one. One or 
both lids may be affected, and the disease is symmetri- 
cal or unilateral. The whole of a lid may be diseased, 
or only places here and there. The eyebrows may 
also be involved with the eyelashes, or be affected inde- 
pendently of them. 

The treatment consists either in pulling out all dis- 
eased hairs, and then smearing on mercurial ointment, 
which is a rapid and radical plan of treatment; or the 
mercurial ointment may be smeared on, and soap and 
water used to wash off the lice and remove the ova. 
As the first plan results in a temporary deformity, and 
the second is quite as effectual though slower, the 
latter is to be preferred. 
17 



OHAPTEE XYIIL 

BEIGEL'S disease, or the chignon FUNGUS; AND 
OTHER PARASITIC DISEASES. 

Besides f avus, ringworm, and pediculosis, there have 
been described from time to time other parasitic dis- 
eases which involve the hair. One of these, known as 
Morbus Paxtonii, has already been spoken of in Chap- 
ter VIII., upon Atrophia Pilorum Propria. In the 
present chapter are included: 1. Beigel's chignon fun- 
gus; 2. Parasitic diseases of the hair connected with 
excessive sweating; and, 3. Some unclassified parasitic 
diseases as reported by different observers. 

1. BeigePs Disease. 

In 1866, Professor Lindemann of Petersburg first 
described a parasite that he found in artificial hair, 
and which he considered a species of gregarine, or 
low form of animal life on the border line between 
the vegetable and the animal world. Shortly after 
this Beigel (44) examined a number of samples of arti- 
ficial hair, and in one, which had been discarded by the 
hair- workers as unfit for use, he found upon each hair a 
number of dirty brown knots which adhered very close- 
ly to it. The hair itself was unaffected, and the knot 
formed a sort of sheath to it. With considerable care it 
could be stripped off without damaging the hair. Micro- 
scopical examination showed that these knots were com- 
posed of micrococci in chains, and of large round cells 
containing two to four large nuclei. The fungus growth 
was pronounced by Kuchenmeister as a new species 



beigel's disease. ^5^ 

of pleurococcus. Hallier (44) subsequently deter- 
mined that they were a new species of Sclerotium, and 
a stage in the development of the well-known peni- 
ciUium. Behrend (3) considers the chignon fungus as 
being a species of Piedra. 

Beigel determined by experiment that the chignon 
fungus was incapable of producing the slightest ill 
effect upon the sldn. It is therefore simply a scientific 
curiosity. 

2. Diseases of the Hair connected with Excessive 
Sweating. 

Various colored nodes surrounding the hair are 
found in subjects who sweat profusely. These are 
met with most often in the axillae, then upon the 
chest, genital regions, and inside of thighs. They are 
of large and small size, completely invest the hair 
sometimes to a considerable length, and adhere closely. 
Behrend (3) says that they are found in twenty per 
cent, of all individuals in Germany. They certainly are 
much less frequent in this country. They occur most 
often in Summer and in those who do not bathe fre- 
quently, and, Mke Beigel's chignon fungus, are of no 
pathological significance, excepting that they may be 
the cause of chromidrosis. 

The color of these nodes is grayish, yellowish red or 
brown. When the hair is dry they are hard, and 
appear under the microscope as sharply contoured 
bodies. When plucked from the sweating skin they 
appear as slimy or gelatinous masses. They are com- 
posed entirely of micrococci, of which several different 
forms have been described. Eberth (598) has met 
with them in the form of colonies composed of round, 
oval and biscuit- shaped bacteria; as bajl- shaped, some- 
what larger, bacteria; and as bacteria in chains. 



200 DISEASES OF THE HAIR AND SCALP. 

The sweat macerates the hair and loosens its cuticle 
in places. In these the micrococci gain lodgment, and 
their growth being favored by the heat and moisture, 
they rapidly increase, still further lift up the cuticle, 
and form nodes. It is possible that they may even 
penetrate between the cortical fibres, though Waldeyer 
is inclined to doubt this. 

Under the title of ^'Dermatomykosis Palmellina,^^ 
Pick (600), in 1875, described similar micrococci dae to 
sweating and occurring in the same situations. But he 
found in his case that the hair was fragile and places 
broken off so as to leave bald spots. Martin (599), 
in 1862, reported a case in which a patch of hair on 
the occiput of a girl recovering from typhoid fever be- 
came golden or yellowish red, and looked as if smeared 
with a yellowish red pomade. In one part of the 
patch the hair had dropped out or was broken off, and 
in other parts it looked as if it had been singed. The 
pomade-like substance was composed of epiphytes, 
the Zooglea Capillorum of Buhl. 

3. Unclassified Parasitic Diseases of the Hair. 

DuHRiNG (597), in 1876, reported a case of parasitic 
disease of the hair of the head in which ova were found 
upon the hair, and papules and pustules on the scalp. 
No insect could be detected about the scalp or person, 
and the ova, though watched for some time, did not 
undergo change. The ova were firmly attached to the 
shaft of the hair, close to the root, and were of elon- 
gated, elliptical shape. One end was glued to the hair, 
the other terminated in a rounded, somewhat tapering 
form. They were firm in consistence, half a hue in 
length, and a twelfth of a Hue in width. Their color 
was straw yellow. From four to a dozen ova were 
fastened to a hair, arranged in rows, close to one an- 



other and pointing obliquely upwards away f rOm the 
scalp. 

Thin (601), in 1882, reported a case of parasitic dis- 
ease of the moustache occurring in a man of good 
health, readily cured, but reappearing once a year for 
five years. It caused a bald strip one quarter of an 
inch broad, extending from the upper to the lower 
border of the moustache. The diseased surface had 
the characteristic appearances of ringworm. The hair 
contained spores similar to the trichophyton fungus, 
but were diseased at their free extremities first, instead 
of at their roots, as is the case in ringworm. 



PAET lY. 

DISEASES OF THE HAIE SECONDARY TO 
DISEASES OF THE SKIN. 



i 



CHAPTER XIX. 

DANDRUFF. 

Synonyms: — Seborrhaea sicca capitis; Pityriasis capi- 
tis; Dandriff. 

The term dandruff or dandriff has been used to des- 
ignate at least four distinct diseases of the scalp, name- 
ly: pityriasis simplex, seborrhoea sicca, eczema ery- 
thematosum or squamosum, and psoriasis; and it is 
probable that a fifth disease, diffuse trichophytosis 
capitis, has been included under it. Properly speaking, 
its use should be limited to that scaly condition of the 
head which is due to seborrhoea sicca or pityriasis sim- 
plex. 

Whether these latter two diseases are identical or 
not, is still an unsettled question. By many authori- 
ties they are regarded as one and the same disease, but 
they present enough points of difference to entitle them 
to separate consideration. I have here placed them 
together for convenience, as they give rise to a some- 
what similar condition of the scalp, and are amenable 
to the same treatment. To draw the line sharply be- 
tween the two is sometimes exceedingly difficult. 

Seborrhoea sicca is a functional disease of the seba- 
ceous glands, in which an abnormal amount of seba- 
ceous matter of abnormal consistence is secreted by 
them. This dries upon the scalp, and either appears 
in the form of thin, fatty plates about the mouths of 
the hair-follicles, or adheres to the hairs in flakes, or, 
if very abundant, heaps up into thick, fatty masses or 
cakes, which cling with a good deal of tenacity to the 



266 DISEASES OF THE HAIR AND SCALP. 

scalp. This latter form is seen very frequenth^ in 
children, during the early months of infancy, and is 
the remains of the vernix caseosa. If portions of these 
crusts or cakes are rubbed between the thumb and fin- 
ger, they will impart an unctuous feeling. The scalp 
in this disease is usually pale or leaden-hued, and when 
the crusts are removed shows no tendency to mois- 
ture, or else exhibits a fatty, glistening surface upon 
which the crust is soon renewed. In some cases more 
activity is shown, and the scalp is shghtly reddened. 
This affection runs a chronic course, is generally most 
pronounced on the vertex, but often is distributed quite 
uniformly over the whole head. Some pruritus at 
times is present, and in some cases, in consequence of 
scratching, there will be excoriations. Seborrhoea of 
the scalp may also take the oily form (seborrhoea oleosa) 
though this is unusual. In that case, instead of the 
scalp being covered with fatty plates and scales, it wiU 
be oily, and the hair shiny. 

Pityriasis simplex, seu capillitii, is essentially an 
interference with the cornification of the upper cell- 
layers of the skin, on account of which, instead of the 
normally compact stratum corneum, we have a con- 
stant shaling off of imperfectly formed epithehal scales. 
The whole scalp may be quite uniformly affected, or 
the disease may be hmited to the vertex, or it may 
occur in circumscribed patches. The scales are thin, 
easily detached from the scalp, sometimes so easily as 
to be readily blown off, and they do not pile up into 
crusts. When rubbed between the thumb and finger 
these scales do not impart the same unctuous feeling 
as do those of seborrhoea sicca, though there is usually 
a certain amount of sebaceous matter present, just as 
in seborrhoea sicca there is always an admixture of 
epithelial scales. Usually the scalp is of normal color, 
though often it is shghtly reddened from hyperaemia. 



DANDRUFF. 26T 

There is never any moisture of the scalp. Pruritus 
often annoys the patient, especiall}' when he is over- 
heated or is using his brain actively, and this inviting 
scratching, excoriations are often met with. 

These two diseases, differing mainly in their essen- 
tial lesion and constituting dandruff, cause annoyance 
by the constant f aUing of the scales upon the shoulders 
of the patient, thus ruining the clothing, or giving it 
the appearance of being powdered; and by the pruri- 
tus which attends them. The hair, too, is generally 
dry, and will not stay smooth after brushing. It is 
for these reasons, in most cases, that the patients ap- 
ply to us for rehef . But dandruff is in many cases the 
forerunner of baldness, and the fact that a long con- 
tinued seborrhoea sicca, or pityriasis, is the most fre- 
quent cause of premature alopecia, should stimulate us 
to use our best efforts to cure the disease. 

Etiology. — Dandruff frequently occurs in strumous 
individuals who are anaemic, and have a sluggish cir- 
culation marked by cold hands and feet. Adolescence 
is its pecuhar time of appearance, and chlorotic girls 
are apt to be annoyed by it. It is an attendant upon 
chronic debilitating diseases, such as rheumatism, 
syphiHs, phthisis, and the like, and comes on after pro- 
found disturbances of the constitution, such as fevers 
and parturition. Dyspepsia and constipation are very 
common exciting causes or aggravants of the disease. 
Improper care of the scalp, the use of the fine-toothed 
comb, and of pomades, hair 'Honics," and hair dyes 
will give rise to the disorder. In some cases there is 
apparently no cause for the disease, but careful inquiry, 
even in these cases, will usually bring out some latent 
cause, such as worry, overwork, mental or nervous 
strain, and the like. Malassez, Thin, Chincholle, 
and some others, claim to have found a parasite as the 
origin of the trouble; and recent experiments by Lassar 



268 DISEASES OF THE HAIR AND SCALP. 

and Bishop would seem to prove that the disease, at 
least pityriasis simplex, is contagious.* 

Pathology.— Seborrhoea sicca is a functional disease 
of the sebaceous glands, no structural derangement of 
them having been found. The normal change of the 
hning cells of the glands into oil globules, which escape 
through the gland ducts as an oily secretion, is imper- 
fectly performed, and instead of an oily fluid we have 
an inspissated fat. Microscopical examination shows 
the crust of seborrhoea sicca to be composed of a gran- 
ular mass of epithelial cells in various stages of fatty 
degeneration, and some oil globules. 

Pityriasis is a consequence of imperfect cornification, a 
condition that sometimes follows a squamous eczema. 
By some authorities, as is stated under etiology, a par- 
asite is maintained to be the reason of the desquama- 
tion. Both Malassez (169) and Chincholle (604), in 
1874, described parasites found in the scales from cases 
of pityriasis capitis, and asserted that they were the 
cause of tlie disease. They described them as oval or 
spherical in shape, and from 2 to 5 mm. in length, 
without mycelia, and forming more or less extended 
sheets upon the surface of the corneous layer of the 
skin, splitting it into layers. These spores of Malassez 
and Chincholle are probably identical with the sac- 
charomyces Sphoericus et ovalis of Bizzozero (603), 
which according to him are found quite generally upon 
the normal human sldn. The question of the parasitic 
or non -parasitic nature of pityriasis capitis cannot be 
considered settled as yet. 

Diagnosis. — Before we can intelhgently treat a case 
of scurfiness of the scalp we must arrive at a correct 
diagnosis, and must differentiate between dandruff on 



* The experiments of Lassar and Bishop will be found m Chapter 
VI., page 96, of this work. 



DANDRUFF. 269 

the One hand and eczema, psoriasis, and diffuse trich- 
ophytosis capitis on the other. 

Eczema is distinguished by the scales not being so 
abundant nor so greasy as in dandruff; by their being 
more parchment hke, as if formed rather of dried 
serum than inspissated fat, and more adherent to the 
scalp; by the disease not being so diffuse, but more hm- 
ited to certain patches, or to one side of the head, and 
implicating contiguous non-hairy parts; by the 
greater amount of hyperaemia; by the moisture which 
is either present or readily induced by scratching; by 
its being far more pruriginous, and by its history. 
If thick crusts are present they will usually be of a 
greenish-yellow color and when removed will expose a 
reddened oozing surface. In eczema there will usually 
be a patch of the disease behind the ears. 

Psoriasis rarely occurs upon the scalp without be- 
ing found on other parts of the body. It occurs in the 
form of circumscribed, round, or oval, reddish, infil- 
trated patches, which if of large size are seen to be 
composed of a number of smaller round patches which 
have joined together at their edges. These patches are 
covered with a thick mass of grayish or white ghsten- 
ing scales which are not greasy, and on being removed 
expose a number of minute bleeding points or red dots; 
and they do not reform as quickly as those of sebor- 
rhoea. The disease tends to form a fringe under the 
hair on the forehead, and sometimes to push its white, 
glistening, scaly surface down upon it, and often pre- 
sents a characteristic patch just in front of the ear, 

Tricliopliytosis capitis (tinea tonsurans), when oc- 
curring as a " ring- worm," should offer no difficulty in 
diagnosis, its circular shape and the presence of 
broken and gnawed-off hairs being pathognomonic. 
The diffuse form is rare, and is to be diagnosed by its 
history of gradual spread from numerous reddish 



270 DISEASES OF THE HAIR AND SCALP. 

points or papules, by its scales not being greasy, by the 
hair being broken off and fragile, and by the micro- 
scopical examination of the hair and scales, which 
will reveal the trichophyton fungus in abundance. 

Besides these three diseases, lupus erythematosus 
may sometimes call for differentiation. It is rarely 
met with upon the scalp, and then occurs in the form 
of a sharply defined patch, with an infiltrated reddened 
base covered by a thin adherent scale, which being 
raised shows on its under side a number of prolong- 
ations, the sebum plugs withdrawn from the follicles. 
It causes loss of hair and well-marked atrophic changes 
in the scalp. 

Treatment. — A good deal in the way of preventive 
treatment of dandruff can be accomplished by the pro- 
per care of the scalp and of the general health. More 
care than is usual should be bestowed upon the oper- 
ations of brushing and combing the hair, washing the 
scalp, and upon the selection of the brush and comb.^ 
Do not wash the head too much. I believe that the 
so-commonly practised daily sousing of the head in 
water is hurtful to the hair and scalp, especially if they 
are not carefully and thoroughly dried afterward, and 
a little oil or vasehne rubbed into the scalp. It is not 
the daily sousing which is objectionable, but the in- 
sufficient after-care. Water renders the hair dry, and 
the daily sousing only washes the head superficially. 
A good shampoo every week or ten days for those per- 
sons exposed to a good deal of dust, and every two or 
three weeks for other people, is sufficient for clean- 
hness. A shampoo composed of soap and water, 
borax and water, or of the yolk of an egg beaten 
up in lime-water, is simple and good, but it must 



* Full directions as to these matters will be found in Chapter III., 
of this work. 



DANDRUFF. 271 

not be forgotten to wash out these materials with 
plenty of clean water and to thoroughly dry the hair 
and scalp. 

Patent hair '' tonics," pomades, washes, and dyes 
are to be avoided. Those containing grease, the 
pomades, are, to use an Anglicism, "nasty," give the 
hair an unnatural lustre, smear the hat-band and 
whatever the hair touches, and, becoming rancid, act as 
local irritants. None of these dressings are needed by 
the healthy scalp, and the proper care of the scalp as 
above indicated will preserve the hair in better condition 
than they will. 

The nearer the body can be kept to the standard of 
perfect health by means of bathing, exercise, and good 
diet, the less hkely is dandruff to develop. When, 
therefore, the disease has appeared, and we are applied 
to for rehef, one of our first inquiries should be con- 
cerning the general health, and our first efforts ad- 
dressed to remedying anything found to be wrong. 
For, important as our local measures are in reheving 
the local disorder, in most cases we must depend upon 
internal treatment to render the cure permanent. The 
internal treatment must be along the lines marked out 
in works upon general medicine — tonics, as cod-liver oil 
and iron, for the debilitated; the acids and bitters for 
the neurotic and dyspeptic; mercurials, podophyllin, 
and the like for the bilious, etc. Duhring (10) recom- 
mends sulphur and the sulphide of calcium as of special 
efficacy; and arsenic sometimes acts well. We should 
insist upon our patient obeying the laws of general 
hygiene and instruct him as to the proper care of the 
scalp. 

Various substances, all of a more or less irritating 
nature, have been recommended for the local treat- 
ment of dandruff. Such are tincture of cantharides, 3 j. 
to J j. ; tinctm-e of capsicum, 3 j. to 3 j. ; tincture of nux 



272 DISEASES OF THE HAIR AND SCALP. 

vomica, 3 j. to 1 j. ; chloral, 3 j. to J j. ; bichloride of mer- 
cury, gr. ij. to iij. to 3 j. ; the oleate and other mercmials 
in proportionate strength; sulphur, 3 j. to 3 j.; carboHc 
acid, gr. x. to xx. to 5 j.; sahcylic acidgr. x. to xx. ad 
1 j ; tar or oil of cade 3 j. to 3 iv. ad 3 j ; quinia, strychnia, 
etc. These are used either in solution in alcohol, water, 
or the oil of olive, castor, rosemary, bene, etc. ; or as oint- 
ments. A good menstruum for their exhibition is com- 
posed of glycerine, 3 j. to ij.,to dilute alcohol, § j. Vase- 
hne forms the best medium for theu^ exhibition as oint- 
ments. Excepting where the hair is decidedly thin, 
so stiff an ointment as the ungt. zinci oxid. should not 
be used, and lard itself is apt to become rancid. Lano- 
lin is too stiff a base unless very much diluted with 
vasehne or oil. The tincture of benzoin is made a con- 
stituent of many lotions for the scalp, and resorcin 
and icthyol have both been commended as remedies in 
seborrhoae. Thus Fournier (607) recommends the fol- 
lowing lotion: 

Beef marrow, 60. 

Oil of sweet almonds, .... 20. 

Flower of sulphur, . . . . 1. 

Tinct. of benzoin, .... 6. 

Ihle's (159) formula for resorcin is: 

Eesorcin, . . . . 5 to 10. 

Castor oil, . . ... 45. 

Alcohol, 150. 

Balsam of Peru, .5 

Sig. Daily rubbed in with a piece of flannel. 
Unna has had good results from icthyol in ointment 
form, ten to twenty per cent strength. 

Heitzmann (608) expects a rapid cure of his cases by 
the appUcation to the scalp of the following ointment: 
Oleum rusci . . . |ss=15. 

Ungt. aquae rosae ad . . ?iv=100. 
01. rosae .... gt. xtoxx=l. 

M. 



DANDRUFF. 273 

This is to be used at night, and the superfluity is to 
be rubbed off with a dry rag in the morning. Twice 
a week the head is to be shampooed with castile soap 
and water. 

Before using any remedy for the dandruff the scalp 
must be cleaned. If there is enough accumulation of 
fat scales to form crusts, the head must be saturated 
with oil, preferably sweet almond oil, for from twelve 
to twenty-four hours, and then washed with soap and 
water. After the hair and scalp have been well dried 
the chosen remedy is to be appUed. In slight cases of 
dandruff the soaking with the oil may be omitted. 

Of all the above remedies, I have been led by experi- 
ence to place my main reliance upon sulphur and the 
mercurials, and would advise the following plan of local 
treatment. If the case presents itself with a decided 
accumulation of scales, or if crusts are present, direct the 
patient to saturate his head with oil, preferably sweet 
almond oil, before going to bed, and place over his 
head a flannel cloth soaked in the oil, and outside of 
all an oiled silk cap. The next morning he should 
shampoo his head thoroughly with soap and water, 
using by preference the tincture of green soap, and 
wash out the soap with plenty of water. The scalp is 
then to be dried by vigorous rubbing with a coarse 
towel, and the hair by pulling it through a soft towel. 
If the crusts by this method are not completely re- 
moved, a little oil should be kept on during the day, 
the head again soaked at night and washed with soap 
and water in the morning. If the scalp should appear 
very hypersemic after the crusts are removed, apply vas- 
eline or simple ointment, as rose ointment, until the 
hyperaemia is lessened. When the crusts are removed 
and the hyperaemia overcome, have an ointment com- 
posed of one drachm of sulphur loti to one ounce of 
vaseline applied every niorni! g to the scalp. If the 
18 



^Y4 DISEASES O^ THE HAIR AND SCALP. 

scales form rapidly, apply the oil every night and the 
sulphur ointment every morning, and wash the head 
every second or third day. As soon as scaling is less- 
ened stop the use of the oil, but continue the ointment, 
at first using it every second morning, then gradually 
reducing its application to once a week. Throughout 
this plan of treatment the head should be shampooed 
about once a week with the tincture of green soap, 
borax and water, or the yolks of three eggs beaten up 
in one pint of hme-water, to which a half ounce of 
alcohol is added. Another excellent ointment for these 
cases, for the formula of which I am indebted to Prof. 
Bronson, of the New York Polychnic, is composed as 
follows: 

Hydrarg. ammon, . . . gr. xx. 
Hydrarg. chlor. mitis, . . . gr. xl. 

Petrolati Ij. 

M. 

This applied once or twice a day has yielded most 
admirable results in a number of cases in simple dan- 
druff. Its consistence being that of a Mayonaise dress- 
ing, renders it an elegant pomade for private practice. 
Its use should be combined with the occasional sham- 
poo, as directed above. 

Prognosis. — Dandruff is curable, though Hable to 
relapse. In some cases the disease will disappear never 
to come back; but these are the exceptions. Quite com- 
monly the condition will return whenever the health i 
becomes deteriorated. We should inform our patients] 
of this fact, and tell them that they will obtain a cure] 
only by persistent, long-continued, and oft-repeated] 
effort. 



CHAPTER XX. 

KERATOSIS PILARIS. 

Synonyms. — Lichen pilaris; Pityriasis pilaris; Icthy- 
osis seu hyperkeratosis foUicularis; Cacotrophia folU- 
culorum (T. Fox.) 

Keratosis pilaris, as its name indicates, is a disorder 
of cornification. It is characterised by a heaping up 
of the corneous cells about the mouths of the hair-folh- 
cles in the form of small conical whitish or grayish ele- 
vations, the skin between them being normal in color and 
texture, though often of a grayish or brownish shade 
from lack of cleanliness and hyperpigmentation. It is 
met with principally upon the extensor surfaces of the 
limbs, the upper arm and thigh being most often affect- 
ed, though it may occur almost anywhere on the body. 
To the eye, the skin has the appearance of what is 
commonly called goose flesh, " cutis anserina. " It is 
seen to be dotted all over with little pin head to small 
pea-sized, conical, whitish, grayish, or blackish papules, 
each of which is either pierced by a hair or has at its 
summit a small black dot, indicating the mouth of a 
hair- follicle. These papules are often scaly, sometimes 
surmounted by a scale. Sometimes the hairs grow 
vigorously from the papules, sometimes they are 
broken off, and sometimes are to be found only by 
opening the papule, when they will be seen curled up 
inside of it. To the touch the skin feels dry, and harsh 
and somewhat like a fine nutmeg grater. 

Subjective symptoms are wanting in most cases, but 
there often is more or less pruritus, especially in chil- 



276 DISEASES OF THE HAIR AND SCALP. 

dren; and in them there may be a shght degree of ec- 
zema on account of the scratching. 

Etiology. — The disease is most often met with after 
puberty, though it may be congenital. It is a very 
common affection of the skin, but, as it gives httle or 
no trouble, we are seldom called upon to treat it. It 
is the result of an inactive state of the skin, and is 
seen most often in those who do not bathe with suffi- 
cient frequence. It is met with in connection with 
icthyosis and prurigo, and is said to follow pityriasis 
rubra. It was formerly regarded as a species of papu- 
lar eczema. 

Pathology.— It is simply an anomaly of cornifica- 
tion, a thickening of the corneous layer of the skin 
about the mouths of the hair-foUicles, by which the 
epithehal cells are heaped up into conical papules. It 
has nothing to do with any disorder of the sebaceous 
glands or of the hair- follicle itself. When this condition 
is congenital and constant in spite of treatment it has 
been named icthyosis follicularis, and corresponds to 
T. Fox's cacotrophia foUiculorum. 

Diagnosis. — It is necessary for us to differentiate 
keratosis pilaris from cutis anserina; the mihary papu- 
lar syphilide; lichen scrofulosus; papular eczema; 
hchen planus, and icthyosis. 

Cutis anserina is a passing condition of the skin in 
which the arrectores pill muscles contract under the 
stimulus of cold, and raise up the hair and immediately 
contiguous parts into papules. Keratosis pilaris is 
constant and uninfluenced by temperature. 

The miliary papular syphilide has its papules 
grouped; they are of a dark red or raw ham color, and 
deep seated, and are only slightly scaly. The syphilitic 
eruption is more apt to be a general one, and fados 
away of itself in a few weeks. The papules of kera- 
tosis are whitish, grayish or blackish, superficial so 



KERATOSIS PiLARiS. St'T 

that they are readily removable by soap and water, 
scaly, and usually confined to the arms and thighs. It 
does not tend to get well of itself. 

Lichen scrofulosus, as generally seen, is in the form 
of well-marked circular or crescentic patches of yellow- 
ish-brown papules upon the trunk, usually upon the 
abdomen. The papules are slightly scaly, and the sub- 
jects generally present other symptoms of struma. 
Keratosis pilaris does not have grouped papules; its pap- 
ules are whitish or grayish, and its subjects are not 
necessarily strumous. 

Papular eczema occurs as an eruption of bright red 
inflammatory papules which tend to run together and 
form patches. It is very itchy, and shows no predilec- 
tion for the upper arm and thigh. 

Lichen planus occurs especially on the anterior face 
of the wrists as a group of dull red or lilac -tinted, an- 
gular, slightly umbilicated, flat papules, and is attended 
with a good deal of pruritus. 

Icthyosis is a congenital affection of the general in- 
tegument, though most marked upon the arms and 
legs. The skin is dry and scaly, and marked off into 
polygonal spaces, and the disease is incurable. Kera- 
tosis pilaris rarely occurs before puberty, is limited to 
the mouths of the lanugo hair-foUicles, and is perfect- 
ly curable. 

Treatment. — The vigorous use of soap and water 
in an alkaline bath will promptly remove the papules. 
The best soap for the purpose is the sapo viridis or 
soft soap, and this may be used in the form of a tinc- 
ture. 

A vapor or Eussian bath may be used for the same 
purpose. After the bath the skin should be anointed 
with oil, vaseline, lanolin, or any emollient. In some 
obstinate cases it may be necessary to use a mercmial 
such as: 



27S DISEASES OF THE HAIR AND SCALP. 

5 Hydrarg. ammon. . . . 3j — ii 

Hydrarg. chlor. mitis, . . . 3ij — iv 
Vaseline, . ad . . . . 5j 

M. 

In congenital cases cod-liver oil should be given by 
the mouth and also inbbed into the affected skin. 

Prognosis. — The disease is perfectly and easily cur- 
able, but without treatment it may last indefinitely. 



CHAPTER XXI. 

ECZEMA CAPITIS ET BARB^. 

The hairy parts of the body are affected with eczema 
either in connection with or independently of eczema 
of other regions. Owing to the presence of the hair, 
and, in some places, as the scalp, to a difference in the 
structure of the under-lying tissues, the disease in 
hairy regions has some peculiar symptoms. We will 
describe eczema of the scalp, of the bearded portions 
of the face, and of the edges of the eyelids. The 
symptoms of the disease, as met with in these regions, 
include all that are to be encountered in any hairy 
region. 

ECZEMA CAPITIS. 

Synonyms: — Crusta lactea; Impetigo figurata, seu 
lactantia, seu mucosa, seu muciflua; Porrigo; Tinea 
amiantacea, seu f urfuracea, seu granulata, seu asbes- 
tina; Melitagra; Achor; Eczema capillitii; Erythema 
ichorosum; Gourme (Fr.); Vesicular or running scall, 
scalled head, milk crust (Eng). 

Symptoms. —By the above and a number of other 
names this very common disease of the hairy scalp 
has been designated. The vesicular, pustular and 
erythematous varieties of eczema occur upon the scalp 
as primary forms far more frequently than the papu- 
lar variety, which is exceedingly rare : squamous ec 
zema is met with as a sequella of the other forms. 
Eczema may affect the whole sc^alp or only a portion 
of it; and it may run an acute or chronic coiu'se. It 



^80 DISEASES OF THE HAIR AND SCAL?. 

may occur either in connection with eczema of other 
parts of the body, or independently. 

Vesicular Eczema. — Eczema vesiculosum is an 
acute disease which breaks out either upon a part or 
the whole of the scalp. The vesicles are so short hved 
that the physician hardly ever sees them excepting 
upon newly formed patches. When the case presents 
itself, the scalp is seen to be swollen, at times so much 
so as to give a boggy sensation to the touch; it is 
moist, and in bad cases exuding so freely that it is 
covered with a sticky, yellowish, mucilagmous fluid. 
The hair is always stuck together in little bundles, and 
if it is long it wall be matted. The head emits a sick- 
ening odor. The exudation dries into hght -yellow ad- 
herent crusts; when these are removed a moist exud- 
ing surface is exposed that soon becomes again crusted. 
This form of eczema may change into the pustular 
form, or it may become squamous. It runs an acute 
course in most cases. 

Pustular Eczema. — Eczema pustulosum occurs as an 
eruption of discrete pustules affecting a part or the 
whole of the scalp. The pustules soon become con- 
fluent, break down and discharge their purulent con- 
tents. The hair is matted together. The exudation 
dries into thick yellowish green or blackish adherent 
crusts and the head emits a foul odor. When the 
crusts are removed a moist exuding surface is left, 
which soon becomes covered with a fresh crust. After 
lasting an indefinite time the pustular form is ex- 
changed for the squamous. 

The pustular form differs from the vesicular form 
in having pustules rather than vesicles; in the char- 
acter of the exudate; in its crusts being darker colored; 
and in having a more disgusting odor. Sometimes 
the pustules are located only about the hair-follicl >s 
and the disease will assume the form of sycosis. At 



ECZEMA CAPITIS ET BARB^. 281 

times there will be marked swelling of the cervical 
glands; and, especially in children, abscesses of the 
scalp may form. 

Erythematous Eczema. — Eczema erythematosum 
usually occurs in patches upon one side of the head 
but may affect the whole scalp. The patches are of 
irregular form, bright red in color, perfectly dry and 
sHghtly scaly. Sometimes the skin may be a little swol- 
len or thickened. If the scales are removed with soap 
and water or slight friction, the skin will become moist 
and exude serum from innumerable pores. This form 
of eczema either gets well rapidly or changes to the 
squamous form. 

Squamous Eczema. — Eczema squamosum on the 
scalp as elsewhere is the final stage through which the 
other varieties of eczema pass on their way to recovery. 
The whole scalp may be affected or only a patch here 
and there, depending upon the nature and location of 
the preceding primary form. It also presents several 
forms. It may be of only slight intensity when the 
scalp will be but slightly thickened, of light-red color, 
and covered with whitish or grayish scales, which come 
off readily in the form of flakes. Or it may be more 
severe, when the scalp will be decidedly thickened, of 
deep- red color, and covered with more or less adherent 
white or gray scales in the form of plates. Or the 
thickening of the skin and the inflammation may be 
yet more severe, and the scalp will be red, scaly and 
cracked. This form of eczema may last indefinitely 
as a chronic eczema of the scalp. 

These are the four varieties of eczema as commonly 
met with on the scalp. The pustular and the squa- 
mous forms are the most frequent, the former especially 
in children, where it constitutes the " nnlk crust." 
The erythematous form is seen chiefly in adults. At 
times there wiU be several varieties of eczema upon the 



282 DISEASES OF THE HAIR AXD SCALP. 

scalp at once— for example, the pustular variety in one 
place and the squamous m another. With eczema of 
the scalp we usually will find a patch of the same 
disease behind or upon the ears, upon the back of the 
neck, or on the face. Sometimes other hairy regions 
will be affected at the same time as the pubes or 
axilla. 

The hair is unaffected as a rule, excepting that it is 
glued together by the serous or sero-purulent exuda- 
tion of the vesicular and pustular forms, and is dry in 
the erythematous and squamous forms. It is only 
when the disease is very chronic that there is baldness, 
which is not permanent; the hair in most all cases 
growing again when the eczema is cured. 

Itching is present in greater or less degree in all 
cases. It is often intense in the erythematous and 
squamous varieties; less marked in the pustular and 
vesicular forms. In the acute stages of the disease 
the scalp will feel drawn, and, may be, painful, and 
there wiU be more or less of a burning sensation. 

The sebaceous glands are usually fmictionally 
diseased in a case of eczema giving rise to a seborrhoea. 
In the crusts of eczema of the scalp oil globules are 
generally found, and in a chronic eczema the dry 
and lustreless appearance of the hair is in part due to 
a deficiency of the oily secretion of the sebaceous 
glands. 

In neglected cases among people who are unclean in 
their habits pediculi find lodgment in the hair; and in 
some aggravated cases of uncleanhness we have devel- 
oped that condition which is described in the next 
chapter as Phca Polonica. 

Etiology. — The etiology of eczema of the scalp is no 
more settled than is the etiology of eczema in general. 
Some authorities, as in the Vienna school, insist upon 
the disease being local in aU cases; some of the French 



ECZEMA CAPITIS ET BARB^. 283 

school are equally positive that eczema is an expres- 
sion of a diathesis; while some, and perhaps these now 
are in the majority, take the safer middle course and 
teach that some cases are due to local causes, and some 
to constitutional conditions. By the use of croton oil 
an artificial eczema can be produced on any skin; but 
that does not prove that eczema is always due to a 
local cause. Water, with or without strong alkalies, 
may be used by a person for years with impunity; then 
there may come a time when it will cause an intense 
eczema of the hands. This seems to show clearly that 
there has arisen in the person some constitutional con- 
dition which renders the skin obnoxious to the use of 
water. Eczema, I believe, may be in some few cases 
a purely local disease; then it has rather the nature of 
a dermatitis and is of short duration. In most cases, 
however, there exists a predisposition to the disease, 
and when the predisposing causes are very pronounced 
and not easily removable, the disease will be very 
chronic and obstinate to treatment. This predisposi- 
tion may be so pronounced that we may speak of the 
person having it as being eczematous, just as we would 
speak of another being rheumatic or gouty. 

The causes of eczema of the scalp are predisposing 
and exciting. Here I do not intend to enter upon a 
discussion of all the causes of eczema as given by dif 
ferent authors, but shall content myself by giving such 
as have special relation to eczema of the scalp. 

The predisposing causes of eczema capitis are, in- 
fancy and a debilitated condition of the system arising 
from any cause. 

Age is an important element in etiology. Children 
under five years of age furnish nearly one-quarter of 
all cases of eczema, "'' and in them the scalp is more fre- 

*Bulkley's Eczema and its Treatment, New York, 188-Jt. 



284: DISEASES OF THE HAIR AND SCALP. 

quently attacked both independently and in connection 
with the disease elsewhere, than is the case in adults. 
In forty-nine personal cases of eczema of the scalp, 
thirty-five occurred in children under five years of age, 
and of these twenty-seven were in connection with ec- 
zema on other parts of the body, mostly of the ears and 
face. In the remaining fourteen cases winch occurred 
in adults six were on the head alone. That children 
should be more predisposed to eczema than are adults 
is due to their skin being more delicate and hence more 
vulnerable. In them, too, we more often see evidences 
of struma, and vices of constitution either inherited or 
acquired. 

A debilitated condition of the system predisposes to 
eczema in general, and hence to eczema of the head. 
Fat anaemic babies are prone to eczema. Over-fed or 
under-fed children, who five in bad hygienic surround- 
ings and are uncared for, furnish some of our most ob • 
stinate cases. Disturbances of the digestion, expressed 
either as nausea, vomiting, diarrhoea, constipation, or 
simply as malassimilation without any tangible symp- 
tom, by their effect upon the constitution of the blood, 
and hence on the nutrition of the skin, predispose to 
eczema. Gout and rheumatism, nervous exhaustion, 
the chlorotic state, predispose to the disease. In al- 
most every case there wiU be found some deviation 
from the standard of health. 

The exciting causes of eczema capitis are all injuries 
to or irritations of the scalp. In children a very fre- 
quent exciting cause is well meant, but badly directed 
efforts at cleanliness. The vernix caseosa is attacked 
too vigorously with soap and water before it is prop- 
erly soaked with oil; the fine-toothed comb is em- 
ployed for the removal of dandruff and the scalp is 
scratched by it; or a too stiff brush is used for the ten- 
der scalp. In both children and adults all cutaneous 



ECZEMA CAPITIS ET BARBAE. 285 

irritants may give rise to eczema, such as mercurial 
ointments applied for the destruction of lice, and the 
like; tincture of arnica for bruises; water fomentations; 
too strong applications for the cure of seborrhoea or 
loss of hair, and the like. Pediculi are very frequently 
the cause of eczema, especially of the occipital region. 
The too vigorous use of the comb and brush may act 
like any other irritant in causing the disease. It is also 
possible that in an infant the growing hair may irri- 
tate the scalp. 

Diagnosis. — A moist eczema of the scalp is easy of 
diagnosis if we remember that in it the scalp is red- 
dened; more or less thickened; exuding in some places 
and crusted in others; itchy; and the hair is stuck to- 
gether as if by mucilage. Only one other disease sim- 
ulates it and that is pediculosis. On the other hand 
the erythematous and squamous forms are at times 
difficult of diagnosis from pityriasis, ringworm, ery- 
sipelas, lupus erythematosus, or a simple dermatitis; 
and pustular eczema of the scalp in its more chronic 
form when it occurs in patches may be mistaken for 
psoriasis, seborrhoea sicca, favus, or syphihs. 

A moist, exuding eczema is to be differentiated from 
pediculosishj its occurrence generally all over the scalp, 
while pediculosis is more limited to the occipital and 
temporal regions. In eczema there are no pediculi 
or ova, while in pediculosis they are readily to be 
found. "When pediculosis is well marked there is al- 
ways a pustular eczema, and in a pustular eczema of 
any continuance there are liable to be pediculi. But 
then the diagnosis is not essential, the indication for 
parasiticides being so plain, that in treatment they are 
to be used first, and afterwards remedies for the ec- 
zema. 

In pityriasis the scalp is but slightly reddened, not 
at all thickened, the scales are abuudaat, readilj^ d^- 



286 DISEASES OF THE HAIR AXD SCALP. 

tached and furfuraceous, the hairs are not stuck to- 
gether, but frequently are found piercing a small scale. 
In eczema the scalp is decidedly red and more or less 
thickened; the scales are moderate in amount, often 
quite adherent, and come off in the form of plates; and 
the hairs here and there may be found stuck together, 
if there are any moist spots on the head. 

Ringivorm occurs in one or more circumscribed, 
round, scaly patches. The patches of eczema are not 
sharply ckcum scribed. In ringworm the hairs are 
brittle, broken off, twisted, and come out readily. 
In eczema the hairs are merely stuck together. In 
ringworm we have stumps of broken hair, which are 
pathognomonic of the disease. The crusts of ring- 
worm are grayish in color, those of eczema are yellow- 
ish or greenish. Ringworm is never moist, has a weU- 
marked history of contagion, the patches spread from 
one point peripherally, and it is not very itchy. Ec- 
zema is generally moist at some time, is not contagious, 
does not develop from one focus, and is very itchy. 
In ringworm the trichophyton fungus is readily de- 
monstrable by the microscope. In eczema there is no 
fungus. 

Erysipelas creeps over the scalp with a sharply cut 
advancing outline; there is a considerable sweUing of 
the integument, and marked fever and constitutional 
disturbance. It runs its comrse rapidly. Eczema has 
an ill-defined border, less swelhng of the scalp, and 
shght if any constitutional disturbance. 

Lupus erythematosus develops slowly in the form of 
a dry, sharply defined, scaly, red patch. In a short time 
there will be loss of hair, and marked cicatrisation in 
the old parts of the patch. The scales are adherent 
and in close relation to the sebaceous glands. In ec- 
zema the patches are not sharply defined, there is no 
cicatrisation nor baldness, and the scales bear no rela- 



ECZEMA CAPITIS ET BARB^. 287 

tion to the sebaceous glands. Lupus is far more 
chronic than is eczema, and less amenable to treatment. 

A simple dermatitis is an acute redness and swelling 
of the skin, arising from some readily ascertainable 
cause, and soon passes away. Should it continue for a 
few days it will pass over into an eczema with the 
characteristics of the latter disease. 

Impetigo is regarded by many authorities as merely 
a pustular eczema, but there is at times an eruption of 
discrete pustules upon the head, which show no ten- 
dency to form patches, being isolated throughout their 
course. To this eruption the name of impetigo is 
given. It is less itchy than is eczema and the pustules 
are larger. 

Psoriasis never occurs upon the scalp alone; char- 
acteristic patches will always be found elsewhere upon 
the trunk or extremities, and often there is a line of 
scaling papules on the forehead along the edge of the 
hair. Eczema is often limited to the scalp, with at most 
a patch of disease behind the ear. Psoriasis is dry and 
occurs as circumscribed, rounded, discrete, small 
patches, or larger ones evidently made up of separate 
smaller ones, and covered with thick whitish or dirty 
grayish crusts composed of heaped- ap epidermic scales. 
When the crusts are removed the under-lying skin is 
dry or slightly moist, with a few minute bleeding 
points. The patches of eczema are larger, and less well 
defined; its crusts are made up of scales, dried pus and 
sebaceous matter, matting the hairs together, and when 
they are removed a moist exuding surface is exposed. 
Psoriasis is less itchy, and there is in it a well-marked 
history of relapses. 

Seborrhcea sicca affects by preference the vertex; 
eczema has no sites of preference. In seborrhoea the 
scalp is normal in color or pale, in eczema it is always 
r^d. The scales aiad ci^usts of seborrhoea are greasy 



288 DISEASES OF THE HAIR AND SCALP. 

to the touch, and gray or yellow in color; those of ec- 
zema are harder, and yellowish green or even black. 
Seborrhoea is a dry disease, eczema is a moist one. 
Seborrhoea is less itchy than is eczema, and in it the 
hair is dry and, may be, powdery, while in eczema it is 
stuck together. Seborrhoea is followed frequently by 
permanent baldness. Alopecia may follow eczema 
but in most all cases it is transient. 

Favus has yellow-cupped crusts which are never met 
with in eczema. Favus has a history of contagion, 
and of spreading from one or two foci; causes bald 
atrophic patches of a peculiar red color; is dry through- 
out its course; only slightly itchy; and has a stale 
straw or mousey odor. Eczema has no history of con- 
tagion; forms rapidly into moist patches; is exceed- 
ingly itchy; does not cause atrophy of the scalp nor 
baldness; and has a sickening odor. 

Syphilis differs from eczema in its whole history and 
course. Its pustules and papules are discrete and unat- 
tended by itching. Its pustules tend to break down and 
ulcerate, and then are covered with striated crusts, 
which being removed expose circular deep ulcers, 
which heal and leave scars^ Nothing like this is met 
with in eczema. 

Treatment. — Constitutional Treatment. — The 
treatment of eczema capitis is both constitutional and lo- 
cal. Excepting where there is some evident local cause, 
such as the presence of pediculi or the use of some irritat- 
ing application to the scalp, it is necessary to enquire 
very carefully as to the action of the various organs of 
the patient, and to use our best endeavors to aid them in 
properly performing their several functions. We must 
regard the patient as a sick man quite apart from his 
sick skin. There is no specific for eczema; each case 
must be treated on its own merits according to the 
principles of general medicine. Arsenic is one drug 



ECZEMA CAPITIS ET BARBiE. ^89 

that is commonly administered in a routine way. In 
most cases it will do no good; in some cases it will do 
harm; and in a very few cases it will render excel- 
lent service. It should be kept as a last resort. The 
acetate of potash is another drug that is used in a rou- 
tine way. It may do good; it probably will do no 
harm. I have seen but little if any benefit from its 
use in this affection, excepting where there is a rheu- 
matic or gouty condition. Tonics, such as iron, 
strychnine and cod-liver oil, are of great service in de- 
bilitated, neurotic, and anaemic subjects, and will often 
aid us materially, especially in infants and children. 

The care of the digestive and allied processes is all 
important. If we question mothers with eczematous 
babies we will find in most cases that the children are 
nursed every time they cry, and consequently at most 
irregular hours; or they are improperly fed either as 
to quantity, quahty, or frequency, being allowed to 
eat ''anything that is on the table," besides numerous 
apples, bananas and cakes between meals, and to 
drink beer, coffee, tea and the like. In adults we will 
find quite as frequently great indiscretions in eating 
and drinking. Now this is all wrong. We must in- 
sist upon an infant being fed at regular intervals and 
with the food proper to its age. We should inquire as 
to the quantity and quality of the breast milk, and the 
health of the mother. Children should not be allowed 
to eat " what is going " for the first few years of their 
life, and cakes, confectionery, pastry, beer, coffee, and 
tea should be rigorously excluded from their dietary. 
In children, as in adults, it is often well to forbid meat 
for a time, especially in the Summer. Children as weU. 
as adults must not drink beer, coffee or tea; it is best to 
limit their fluids to milk and water. It is not possi- 
ble here and now to lay down any hard and fast rules 
as to diet; my object at present is to insist upon the 
19 



^90 DISEASES OF THE HAIR AND SCALP. 

importance of regulating the diet of an eczematous 
patient. 

The action of the bowels is to be regulated, prefer- 
ably by diet and exercise; by drugs if we must. In an 
acute case, a sharp pm^gative will be found useful, and 
my preference is for the old-fashioned remedy, calomel. 
It is best given in small, repeated doses, say to an adult 
one or two grains repeated every two hours till two or 
three doses are given. It unloads the bowels, and stimu- 
lates the hver. Byford ^ lays special stress upon this lat- 
ter action in explanation of its good effect in eczema of 
children, and beheves that as in them the liver is larger in 
proportion than in the adult, hver indigestion is proba- 
bly an important etiological factor in the disease. He 
gives a quarter to an eighth of a grain of calomel twice 
a day to an infant imtil shght purgation is caused, and 
afterwards as often as the bowels need it. In children 
over two and one half years of age he gives a single 
purgative dose every six to eight days. The adminis- 
tration of calomel is also of service in chronic cases in 
adults, and I often give it in the form of tablet 'tritu- 
rates in doses of from a tenth to a fifth of a grain three 
or four times a day for three or four days and then stop 
for a few days. PodophyUin may be used in propor- 
tionate doses and for the same purpose, and also with 
good results. Acids and alkalies are useful in appro- 
priate cases for the regulation of the digestion. 

Local Treatment. — The indications to be met by 
the local treatment of eczema are to soothe an acutely 
inflamed skin; to stimulate it when in a state of sub- 
acute or chronic inflammation; and to protect it when 
it is endeavoring to reassume its normal condition. 
To know what we want to accomplish is of more im- 
portance in this disease than to know what is the lat- 

* Jour. Amer. Med. Assoc, 1885, V. 317. 



ECZEMA CAPITIS ET i^ARhM ^01 

est drug that is '^ good for eczema. " Before using any 
remedy all crusts and scales must be removed by soap 
and water, and after that is accomplished no water 
should be used upon the scalp excepting at intervals. 
If our remedies are properly used, crusts will not re- 
form. Stiff ointments should not be used on hairy parts 
where the hair is thick, as it mats the hair and makes 
the scalp more unclean than before. Alcohol, water, 
oil and vaseline are our best excipients. The hair need 
never be cut, and should never be sacrificed in women. 
In young children and in boys our treatment is ren- 
dered easier by cutting the hair, but it is not neces- 
sary. In applying remedies to the scalp they should 
be worked in, and not merely smeared over it. 

In an acute moist eczema of the scalp, the head 
should be saturated with olive or sweet almond oil, and 
covered with a linen cap. The oil should be reapplied 
until the acuteness of the inflammation has subsided. 
Sometimes the addition of an alkah to the oil will be 
useful, such as the bicarbonate of soda or borax ( 3 iv to. 
viii. ad. Oj); or lime-water in equal parts with oil. A 
weak carbolized oil, say one per cent, of carbolic acid, or 
glycerine diluted with water, answers admirably in some 
cases. In a few days the acuteness of the disease wiU sub- 
side under this soothing plan of treatment. Then the 
scalp is to be thoroughly cleaned with soap and water, 
and the treatment proper to the condition of the scalp 
used. The scalp will bear stimulating applications much 
better than the rest of the integument; so as soon as the 
acuteness of the disease is past we can use a weak tar 
lotion, say half a drachm of oil of cade to the ounce 
of olive oil. 

In acute erythematous and papular eczema, besides 
carbolized oil or vaseline we may use black Avash, or 
a weak white precipitate ointment, say ten to twenty 
grains to the ounce. The squamous stage wiU soon 



292 blSEASSS OF THE HAIR AXD SCAL^. 

be reached and more stimulating measures called for. 
The treatment for acute moist eczema will be appro- 
priate for an acute pustular eczema when it occurs in 
a violent outbreak of pustules forming patches and 
discharging freely. As generally met T\ath, this form 
of eczema occurs in patches covered with crusts. The 
crusts must be first removed by soaking them in oil 
for twelve or twenty-four hours, and then washing the 
head with soap and water. After the scalp is clean it 
is to be freely anointed with oil either carbohzed, or, 
better, with oil of cade, half a drachm to one drachm 
to the ounce. Sometimes sulphur one drachm in vase- 
line one ounce will do good service in this form of ec- 
zema; but it is uncertain, and apt to prove irritatmg. 
Mercurial ointments, say of calomel twenty to thirty 
grains to vaseline one ounce, or that of the white pre- 
cipitate ointment already spoken of will be beneficial. 

When the squamous stage is reached we need stim- 
ulation, and for this the best remedies are frictions 
with soap and water, and preparations of tar. Once 
or twice a week the scalp is to be washed with the 
tincture of green soap, or equal parts of soft soap and 
alcohol, or if the scalp is very tender and irritable a 
milder soap such as Sarg's liquid glycerine soap, or 
pure castile soap may be used. The washings should 
be repeated at intervals of a few days to a week or 
more according to their effect on the scalp. If they 
prove very irritating they are to be less frequently 
used. After washhig, the scalp is to be carefully dried 
and anointed with some oil or soft ointment contain- 
ing tar such a? ; 



01. Cade, 


3ss— i3=2 to 16. 


01. OHvse ad, . 
1. 


!j = 30. 



and this is to be aj)plied every moriiing and evening. 



ECZEMA CAPiTIS ET BARBJE. ^&S 

Instead of the olive oil as a vehicle we may use vase- 
line, oil of sweet almonds, or agnine or lanoline di- 
luted, as with castor oil, sufficiejitly to make them 
supple. This has proved itself to be in my hands the 
most efficient mode of treating subacute and chronic 
eczema of the scalp. Its only objectionable feature is 
its odor, and this is so pungent and persistent that 
many patients will not use it. Unfortunately we have 
no means of successfully disguising the odor. Instead 
of the oil of cade we may use pix liquida or the oleum 
rusci, but there is no particular advantage in these 
other forms of tar, and the odor is the same or worse. 
The oil of cajeput may be substituted for the tar in 
five to ten per cent, strength, but it is not so good. Car- 
bohc acid ^ve to fifteen grains to the ounce may be 
used, and salicylic acid in three to five per cent, 
strengths. 

Instead of using oily applications we may sometimes 
do better with oil of cade or pix liquida exhibited in 
alcohol, one to two drachms to the ounce. Bulklev 
(5) recommends a lotion composed as follows: 



Acetate of lead, 


gr. viij. 


. .5 


Oil of bergamot, 


3ss 


2. 


Castor oil. 


. 3iv . 


00* 


Alcohol ad, 


3iv 


120. 


M. 







Napthol /?, napthalin, pyrogallol, in the strength of 
five to ten per cent, may be tried if other things fail. 
Eesorcin has of late been highly commended by Ihle * 
and others; and icthyol by UNNA.t In many cases of 
eczema in which the scalp is nnich thickened, the 
treatment is best begun by having the patient wear a 
close-fitting cap made of sheet rubber, and its use con- 

* ^lonatshft F. pra,kt. Derm. 1885, IV. 430. 

f Monatshft F. prakt. Derm. 1886, V. Erganzung-sheft No. 3, in Mai. 



204 DISEASES OF THE ifAiR AND SCALP. 

tinned till the scalp becomes moist and less thick. 
Then tar may be employed. 

After the eczema has been cnred the scalp may be 
left dry and scaly, and then it should be treated ac- 
cording to the principles given in Chapter XIX. on Dan- 
druff. 

Prognosis. — Though eczema capitis is a very obstin- 
ate disease at times, still it is perfectly curable. Some 
cases yield readily to treatment, v^hile others will tax 
om- patience and resources to the utmost. 

ECZEMA BARB^. 

Synonyms: — Impetigo sycosiforme; Achor barbatus; 
Barber's itch. 

Symptoms: — Eczema of the beard, w^hich has been 
often erroneously caUed "barber's itch," has nearly 
the same symptoms as eczema of the scalp. It may 
be of the erythematous, vesicular, papular, pustular or 
squamous variety, though by far the great majority of 
cases are of the last two forms. The erythematous, pap- 
ular, and vesicular varieties have precisely the same 
clinical picture as the corresponding affections of the 
scalp. Most all of the cases are pustular in character 
and we shall speak only of that form. 

Pustular eczema of the beard may be either acute or 
chronic; may affect only one limited area, or the whole 
beard; may be either symmetrical or asymmetrical; 
and it may be confined to the bearded portion of the 
face or pass over to the unbearded portions and to the 
neck. Not infrequently the eyebrows and eyelashes 
will be affected at the same time and in the same way. 
When the disease is acute the affected part or parts 
are swollen, tender and red, and feel stretched and 
burning. Upon the red skin there ^vill be an eruption 
of small pin-head sized pustules which have no special 
relation to the hairs, though many of them do occur 



ECZEMA CAPITIS ET BARB^. 205 

about the months of the hair-foUicles. These pustules 
break of themselves in a very short time and discharge 
their purulent contents, v^hich glues the hairs together. 
If the disease is very acute and violent the beard will 
look as if some mucilaginous fluid had been poured over 
it. Soon the exudation v^ill dry into greenish or yel- 
lowish-green thick crusts, in which the hairs will be 
entangled and matted together. When the crusts are 
removed a moist exuding surface will be exposed. 
The hair will be unaffected excepting that it is stuck 
together; and attempts at epilation will be painful. 

In subacute and chronic cases the hair will be some- 
what thin, leaving the under-lying skin exposed. This 
will be red and scaling in some places, covered with 
greenish crusts in other places, and studded here and 
there with small pustules, either about the mouths of 
the hair-foUicles or independently of them. It will be 
seen that the skin between the hairs is diseased as well 
as about the hairs. To these subacute and chronic 
cases sycosis is apt to join itself, or the eczema may 
pass over into a sycosis. 

Squamous eczema of the beard is the final stage of 
the other varieties, through which they pass on their 
way towards recovery. In it the skin is reddened and 
thickened and covered with scales. Very often the 
progress of the disease is stayed at this point and re- 
covery does not set in. On the contrary, relapses are 
Hable to occur even after the squamous stage has lasted 
for some time. 

Itching accompanies all varieties of eczema of the 
beard, and is, excepting the deformity, the most an- 
noying feature of the disease. 

Etiology. — This form of eczema is comparatively 
rare. In 1800 consecutive skin cases occurring in Dr. 
Geo. Henry Fox's service at the New York Skin and 
Cancer Hospital, it was seen only sixteen times. Of 



^06 DISEASES OP TEEE HAIR AND SCALP. 

course it occurs only in men. It is predisposed to by 
the same constitutional disturbances as we noted un- 
der eczema of the scalp. Its exciting causes are also in 
large part the same as noted in the previous section of 
this chapter. Exposure to dust and wind and weather; 
the irritations from tobacco smoke, or the secretions 
from nasal catarrh; the application of poultices for the 
relief of neuralgia; scratching of the beard eitiier 
from habit or on account of the itching due to seborr- 
hoea, and shaving, may be noted as special exciting 
causes. 

Diagnosis. — Eczema of the beard is to be diagnosed 
from sycosis, trichophytosis barbae, acne, a pustular or 
tubercular syphilide, and an epithelioma. 

Eczema is a more superficial process than sycosis; 
its pustules have no close relation to the hairs, it is 
very itchy, its crusts are thick and seated upon a moist 
and oozing surface, the hair is unaffected, and it is 
often associated with the same disease on other parts 
of the face or general integument. Sycosis is a deep 
perifollicular inflammation, its lesions are seated about 
the hair- follicles, the skin between the hairs being 
unaffected except in old and severe cases, its crusts 
are not so thick as those of eczema and do not mat the 
hairs together, and it occurs only upon places supplied 
with hair. It burns rather than itches, and the hairs 
are readily pulled out. 

Trichojjhytosis barbae has a history of spreading 
from one or two points, and often can be traced to a 
source of contagion. It is generally confined to the 
chin and throat, and its lesions are tubercles and nod- 
ules. The hair is early affected, is broken off and is 
readily pulled out, or falls out of itself. The crusts 
are small or wanting. It often extends beyond the 
beard as a typical ringworm, or ringworms may be 
found on other parts of the body. These symptoms 



ECZEMA CAPITIS ET BARB^. 297 

are so characteristic that the two diseases should not 
be confounded. 

Acne occurs as isolated and discrete pustules or small 
cutaneous abscesses on all parts of the face, and come- 
dones are generally to be found. The skin between the 
pustules is unaffected; there is no exudation, and no 
itching. 

In syphilis there will be other lesions elsewhere on 
the body, and a history of an initial lesion or of some 
other manifestation of the disease. The lesions are 
discrete, and if there are crusts, well-marked specific 
ulcers will be found beneath them when they are re- 
moved. 

It would hardly seem possible to confound an eczema 
with an epithelioma, but it has been done. An epith- 
elioma occurs as a single lesion, rounded or irregular 
in outline, of varying size from that of a one -cent 
piece to that of the palm, and forms a well-marked ulcer 
with raised hard waxy borders over which run delicate 
branching blood-vessels. The ulceration may be only 
superficial and covered with a delicate crust, but it is al- 
ways sharply defined and bleeds easily. An eczema has 
no well-defined shape or border, and no raised edge. 
An epithelioma is painful, the pain being lancinating 
at times, while an eczema is itchy. 

Prognosis. — The obstinacy of the disease, and it is 
often exceedingly rebellious to treatment, is due to 
the irritation of the skin by the stiff hairs of the beard. 
Though the disease is obstinate it is perfectly curable; 
but it is liable to relapses, and it is good policy to let 
our patient know this before beginning treatment. 

Treatment. — The treatment of eczema of the beard 
is conducted on the principles we have learned in 
studying the same disease of the scalp, but modified 
in some particulars to suit the changed conditions. 
Whien we can prevail upon the patient to cut his beard 



298 DISEASES OE THE HAIR AND SCALP. 

close, we have taken a long step towards curing the 
disease. Many patients prefer to allow the beard to 
grow, as it serves to disguise the disfigurement to a 
certain extent: but we can apply our dressings much 
better if we get rid of the hair. Shaving may be prac- 
tised and is recommended in many text-books : but it 
is very painful in the acute stage of the disease and 
unnecessary if the hair is cHpped close. In the squa- 
mous stage it should be advised because of its stimula- 
ting effect. The first step in treatment is to remove 
from the patient any irritant that has been acting upon 
his skin. If the case is a bad one we should have the 
patient stay at home until the violence of the disease 
is abated. Even then a cure can be secured more 
speedily if the patient will consent to stay in the house 
during its whole course. 

In acute eczema of the beard, after the hair is cut 
close, a soothing apphcation should be used. To this 
end we may employ a carbolized oil, simple oil, black 
wash, lime-water and oil, zinc oxide ointment, simple 
ointment, or Lassar's paste, the latter composed as 
foUows: 

Starch, 

Zinc oxide, . . . aa3ij=8. 

Vaseline ad, . . . . Ij =32. 

M. 

answers admirably. Diachylon ointment is also excel- 
lent. Whatever dressing is selected it should be used 
freely, the ointments being spread thickly upon cloths, 
and bound down to the part with a roUer bandage. 
In Vienna even the acute cases are treated by scrubbing 
the skin with green soap or its tincture and following 
this with the diachylon ointment. 

As soon as the acuteness of the disease has some- 
what subsided we should proceed to more active meas- 



ECZEMA CAPITIS ET BARB^. 290 

ures. All crusts must be gotten rid of by soaking with 
oil and subsequent washing with soap and water. All 
hairs protruding from pustules should be plucked from 
their folHcles. Now the tar preparations spoken of in 
the section on eczema capitis may be used, or mild 
sulphur ointment. Lassar's paste with the addition 
of about fifteen grains of sahcylic acid to the ounce is 
soothing and efficient at this time. When the squam- 
ous stage is reached the beard should be shaved off 
every day or so, and then the stimulating remedies ap- 
plied. As the disease becomes reduced to a slight red- 
ness and the patient is going about his usual avoca- 
tions, the skin should be protected by a shght film of 
vaseline or ointment, or with a dusting powder. In 
fact throughout the treatment, if the patient is obliged 
to go out he must protect the skin in this way, and 
employ the more radical dressings at night. 

ECZEMA PALPEBRARUM. 

This form of eczema, which is also called Eczema 
marginis ciliaris palpebrarum, and Blepharitis ciliaris, 
is seen by the opthalmologist more often than by the 
dermatologist. Thus in 1800 skin cases at the New 
York Skin and Cancer Hospital in Dr. Geo. Henry 
Fox's service, it was noted only five times, though it 
doubtless occurred more frequently than that would 
indicate. Eczema of the eyelids usually accompanies 
the same disease on other parts of the head, though it 
may occur on them alone. It is always pustular in 
character at first, and afterwards squamous. The 
edges of the lids are swollen and rounded, and more 
or less thickly strewn with pustules that quite com- 
monly are situated about the cilia and take on a sycosi- 
form character. The lids after sleep are stuck to- 
gether so as to be opened with difficulty. The pustules 
rupture, and then the edges of the lids become cov. 



300 DISEASES OF THE HAIR AND SCALP. 

ered with yellowish or greenish crusts. When the 
crusts are removed excoriations are left, and some- 
times even small ulcers. The skin itches, and the rub- 
bing by the patient for its rehef aggravates the disease. 
When the process passes over into the squamous form 
the edges of the Hds are merely red and scaly. If the 
inflammation about the cilia has been intense and ul- 
cers have formed, cicatrisation will follow and loss of 
the eyelashes. Both hds are usuaUy affected, and the 
disease is commonly symmetrical. 

With the blepharitis there will be more or less con- 
junctivitis, with its characteristic symptoms. The 
eyebrow, also, is often eczematous. Sometimes the 
disease will remain confined to the corners of the eye, 
especially the outer canthus, for a long time. 

Etiology. — This disease is seen most commonly in 
strumous subjects, and is a frequent complication of 
phlyctenular ophthalmia and other strumous eye trou- 
bles in children. When occurring with eczema else- 
where it is an expression of the eczematous condition. 
When occurring alone it is most frequently caused 
either by some trouble with the eye itself, or by appli- 
cations made to the eye for the rehef of such troubles. 
Sometimes it is difficult to determine whether a con- 
junctivitis has caused the eczema, or an eczema has 
provoked a conjunctivitis. 

Treatment. — The eyes should be bathed with warm 
water to remove the crusts, and then anointed to 
prevent their sticking together. This should be done 
especially before the patient goes to sleep. What oint- 
ment is to be used will depend upon the condition. In 
mild cases simple ointment wiU suffice. Generally 
some form of mercurial ointment wiU do better, such 
as that of the red or yellow oxide diluted eight or ten 
times with vaseline or simple ointment. A. K. Robin- 
son recommends an ointment composed of one grain 



ECZEMA CAPITIS ET BARB^. 301 

of the biniodicle of mercury in one ounce of vaseline. 
Deligny has found the best apphcation to be: Plumbi 
acetat. .25. Adeps. 25, Lawson regards ointments as 
too irritating, and advises the following wash: 

Boracis vel zinc oxid, . 3ij say 1.5 

Glycerin, . . . 3iv " 3. 

Aquae sambuci, . . iij ^' 12. 

Aquse destil ad, . . 1 viij ' ^ 100. 

M. 

Whether we use ointments or lotions we must be 
sure that any powders that enter into them are of the 
finest, so that matters are not made worse by the irri- 
tation of coarse grains left by the apphcations. 

When the process becomes sycosif orm the ciha must 
be pliicked from the lids. If the disease prove very 
obstinate we may avert the lids and brush over them 
a solution of caustic potash, ten grains to the ounce, 
absorbing the superfluous fluid with blotting paper and 
then washing with water. This should be done every 
day until there is an amelioration of the symptoms, 
when one of the mercurial ointments may be used. In 
all cases constitutional treatment must be prescribed, 
as weU as special treatment for the eyes. 

ECZEMA OF OTHER HAIRY PARTS. 

The hair on any part of the body may be attacked by 
eczema and give rise to symptoms corresponding to those 
just detailed. Thus we have eczema of the axiUa and of 
the pubes; a very annoying eczema of the hairs in the 
nostrils; and a peculiar form of follicular eczema which 
affects the hairs of the extreniities or trunk. 

The treatment of eczema of the axiUa and pubes is 
the same as for the same disease of the beard. Ec- 
zema of the hairs of the naves is often obstinate. We 
must endeavor to cure the nasal catarrh that is usually 



I 



302 DISEASES OF THE HAIR AND SCALP. 

present, and to apply ointments to the part on pledgets 
of lint. Sometimes we may have to epilate and apply 
a solution of nitrate of silver. Hardav^ay * beheves 
this condition is associated in many cases v^ith a 
broken-down state of health, and recommends active 
internal treatment. For the local treatment he has 
found Squire's glycerole of the subacetate of lead of 
special service. This is made by mixing together ace- 
tate of lead 5 parts, litharge 3^ parts, and glycerine 20 
parts, by weight, heating to 350° F. and filtering 
through a hot-water funnel. He opens the little ab- 
scesses with a knife and when the disease is abated ap- 
plies 

Squire's glycerole plumb, subacetat, 3 ss say 2. 

Glycerine, . . . . 3iss " 6. 

Ungt. aq. rosae ad, . . . 5j " 32. 

Cerse albae, qs. " qs. 

M. ' 

In very obstinate and relapsing cases he epilates 
the offending hairs by electrolysis. Eczema seated 
about the hair-follicles of the trunk and extremities 
is, happily, rare, and is sycosic in its nature. I have 
seen it only in a very few cases and then upon the legs 
of strumous subjects. It occurs as disseminated and 
discrete papules and pustules pierced by hairs, and is 
very itchy, so that excoriations are frequently seen. It 
has always proved obstinate to treatment. A cure can 
be effected only by attention to the general physical 
state. Locally the disease is to be treated on the prin- 
ciple of sycosis. 

* Jour. Cut. and Ven. Dis., 1886, IV. 360. 



CHAPTER XXII. 

PLICA POLONICA. 

Synonyms: — Trichosis plica; Trichoma; Koltun (Po- 
lish); Weichselzopf (Ger.); Plique polonaise (Fr.); 
Polish ringworm (Eng.). 

Symptoms: — The term Plica Polonica is used rather 
to designate a condition than a disease, the condition 
arising from various causes and producing the cHnical 
picture of the long hair of the head or other parts 
matted together into various shaped masses, in and on 
which rest all sorts of extraneous matters deposited 
from the floating dust of the atmosphere, and very 
often vast hordes of pediculi with their ova. At times 
these masses of matted hair will be close to the skin or 
scalp; at times removed to a considerable distance 
from it. If close to the scalp we will find beneath 
them a moist and oozing condition of the under-lying 
part; if at a distance from the scalp, the latter may be 
of normal appearance, or scaly. This is due to the 
age of the plica, the freshly formed ones are near the 
scalp, and when the disease of the scalp is recovered 
from, the growing hairs will push the mass further and 
further from the scalp until it either falls off of itself 
or is cut off. Various names have been used to desig- 
nate the different shapes these masses may take; thus 
when the hair is short and there are many locks 
matted separately it is called plica multiformis, or 
caput Medusa; when but a single coil, and this long 
and in the shape of a tail, it is called plica caudif ormis, 
and such tails may be so long as to reach below the 
knees. The odor of the head in plica polonica is pene- 




A CAUPIFOBM Plica Palonica. 



PLICA POLONICA. 805 

trating and disgusting; somewhat like that of rancid 
fat. There are no special constitutional symptoms; 
the patient may be cachectic, strumous, phthisical or 
what not; or he may be perfectly sound and healthy. 
The only subjective symptom is itching. 

Such is the disease as viewed in the light of modern 
medicine since the time when Hebra demonstrated its 
dependence upon lack of care of the hair. Previous to 
that it was described as a disease with four stages 
namely: 1. Prodromal stage; 2. Stage of exudation; 
3. Stage of efflorescence; 4. Stage of convalescence. 
It was regarded as a safety-valve in severe illnesses, 
and it was thought that if the patient could raise a 
pHca he would recover from his disease. It was on 
that account held sacred from injury, and cases were 
reported in which a man or woman died in conse- 
quence of cutting off his or her plica. Phcas have 
been described as having taken on a fleshy condition, 
and reported as having bled from the stump when 
cut off, or at least to have exuded a reddish fluid. 
These were without doubt errors in observation. 

Etiology. — The cause of this condition of the hair 
is want of cleanliness combined with the presence of 
lice, giving rise to pediculosis; or of any disease of the 
scalp which is accompanied by moisture, principally ec- 
zema. But this was not always thought to be the case, 
and the literary war was long and stubborn before this 
theory gained the victory over the old theories that 
regarded the condition as a specific disease. It used 
to be regarded as a dyscrasia occurring endemicaUy in 
certain countries, especially in certain provinces of Rus- 
sia and Poland. It was thought to occur at the crisis 
of many diseases, and was regarded as of favorable 
prognosis. The common people had such great faith 
in the salutary influence of a plica that they often pro- 
duced one by the use of wax, pitch and the hke. 
20 



306 DISEASES OF THE HAIR AT^D SCALP. 

Such an one was called a false plica. It was and 
even now is endemic in certain parts of Poland, and 
especially in the low-lying provinces, because the 
people are wonderfully careless about personal cleanli- 
ness, and are in the habit of wearing fur caps con- 
stantly upon their heads, inducing sweating and favor- 
ing an eczematous condition. It is seen both in men 
and women, and while most common amongst the 
lower ranks of society, it is met with also in the nobihty 
of Poland and Eussia. We encounter the condition 
now and again in this country, but of mild grade, and 
as an unmistakable result of want of care of the scalp. 

Treatment. — The condition is removed very readily 
by soaking the hair with oil, washing with soap and 
water, and carefully combing; all combined with the 
exercise of great patience and perseverance. If the 
mass has grown away from the scalp the easiest way 
of treating it is by cutting it off. After the pHca is 
disposed of, we must apply ourselves to the cure of the 
disease of the scalp that is at the bottom of the 
trouble. The older writers endeavored to treat the 
disease by internal medication. Eosenberg (76) gives 
seventy remedies recommended at different times for 
the cure of the disease. 

Besides this true or plica polonica, there is a form of 
felting of the hair which is apparently due to nervous 
influences, probably of an hysterical nature. Cases of 
this kind have been reported from time to time under 
the name of neuropathic or nervous plica. Eecently 
Le Page (620) has reported a case of spontaneous and 
rapid felting of the hair in a girl seventeen years of 
age; and Pestonji (623) has related another occurring 
in a woman twenty years old. In both cases the hair 
had been wet before it began to twist up, and in both 
there was headache and an entire absence of disease of 
the scalp. 



OHAPTEE XXIII. 

DERMATITIS PAPILLARIS CAPILLITH. 

Synonyms : — Dermatitis papillomatosa capillitii; 
Framboesia; Sycosis framboesia (Hebra); Sycosis 
capillitii (Eayer); Mycosis framboesioides or acne 
keloidique or Pian ruboide (Alibert); Acne keloid. 

Symptoms: — This exceedingly rare disease of the 




Dermatitis Papillaris Capillitii. 

skin was first described as a separate entity by Kaposi 
(629) in 1869. The same group of symptoms had al- 
ready been described by Alibert in IS 14, but regarded 
by him as a manifestation of syphilis. From time to 
time the disease had been observed and mentioned by 
the older authorities, and to it the name of Fiamboesia 



SOS DISEASES OF THE HAIR AND SCALP. 

had been applied on account of the resemblance of its 
peculiar lesions to a raspberry, that being the mean- 
ing of the word " framboesia. " Both in Hebra and 
Kaposi's Lehrbuch der Hautkranhheiten 1872, 
and Kaposi's Pathologie und Therapie der Haut- 
krankheiten,^' 1880, the disease is placed in the chap- 
ter or section on sycosis. Kaposi, in the article re- 
ferred to and in his book, described the disease as fol- 
lows: "The primary manifestations consist of an 
eruption of large and small papules which are very 
hard, of uniform consistence, and contain no pus. 
These lesions are elevated many hues above the skin, 
and form variously sized, deeply furrowed, uneven, 
lobulated tumors. They generally are covered with a 
thick epidermis, bleed only when cut or deeply 
wounded, are rarely moist, and then but in a few 
places; and the few vesicles or pustules that may be 
present are superficial and purely accidental. Th3 
papules are discrete at first, but soon run together to 
form the tumors, which at last flatten down into cica- 
tricial tissue. The hair is deeply seated in the furrows 
between the lobules of the tumors; is formed into ht- 
tle bundles or wisps; and resists attempts at epilation, 
often breaking instead of coming out. Sometimes, on 
the other hand, it seems to be retained only mechani- 
cally in the furrows, and comes out easily when pulled 
upon. It often appears atrophied, and sometimes is 
entirely wanting in large areas, but never is connected 
with a pustule. The disease begins in most cases upon 
the occiput low down at the edge of the hair, and from 
there spreads upwards; sometimes involving the whole 
posterior part of the head. When so extensive, the 
lesions form a papiUomatous vegetation which exudes 
a foul-smelling secretion, bleeds easily and is covered 
with crusts; sometimes abscesses form." 
Hans Hebra, Jr. (626) m 1874 reported a case of ' 'syco- 



DERMATITIS PAPILLARIS CAPILLITII. 309 

sis f ramboesioides ' ' which occurred upon the side of the 
head in the form of raised and sclerosed patches sown 
with millet -seed sized papules and somewhat larger pus- 
tules, out of which protruded little bundles of hair. In 
1881 Sangster (630) reported a case of papillary tumor 
of the scalp which was about the shape and size of a 
pigeon's egg; situated low down on the occiput; about 
half an inch in height; studded with hempseed seized 
papules; brown colored at the circumference, violaceous 
toward the centre; slightly ulcerated here and there, 
with thin crusts. It had begun at birth, and was in- 
creasing gradually in size. The hair was plentiful at 
the margin, but sparse and devoid of pigment towards 
the centre, and grew up between the papillae without 
piercing them. There was a second tumor over the 
left ear. Kaposi pronounced this to be a case of der- 
matitis papillaris capillitii. Hyde (628) has reported 
two cases, in each of which puncture caused a dis- 
charge of mucoid fluid followed by an exudation of 
thin venous blood and serum. He describes the first 
stage as an eruption of pin-head sized papules, vesicles, 
or vesico-pustules. Baker (625) and Williams (632) 
have reported cases under the name of ''Acne Ke- 
loid. " Hervouet (627) reported a case of papiUii- 
form hypertrophy of the scalp, which corresponds in 
many particulars to the disease as described by Kaposi. 
Yeritee (631) has also reported a case under the name 
of Acne Keloidique. 

Through the kindness of Dr. Geo. H. Fox, of New 
York city, I am able to add the following case which 
I had the opportunity of studying with him: J. R., 
set. 30. Large, well-developed and healthy man. One 
year ago (1881) there appeared on his neck an eruption 
of hard nodules, which have been steadily increasing 
in number and size., The eruption is situated upon 
the occiput amongst the hair, and upon the contigiious 



310 MSEASES OF THE HAIR AND SCALI*. 

portions of the neck. It consists of numerous small, 
reddish, hemispherical tumors, each one of which is per- 
forated by hairs. A few of these tumors showed a 
tendency to suppurate about the mouths of the folli- 
cles. Some of the tumors tend to become aggregated, 
and to form mulberry-like masses of dull red color. 
The smaller nodules are very firm, and hard and shotty 
to the touch. They do not bleed readily when punc- 
tured. They are not tender nor sore, and he is troubled 
only by the deformity caused by their presence. 

From a study of these cases we learn that the dis- 
ease begins as an eruption of papules of small size, 
which are usually few in number, and situated upon 
the back of the neck at the margin of the hair. These 
papules are of the color of the skin, or slightly more 
reddish, and sometimes have an inflammatory halo. 
They are exceedingly hard and firm, and do not con- 
tain pus. If pricked they give vent to a little bloody 
serous fluid. Slowly they increase in number, and 
form larger raspberry -like elevations which have un- 
even, lobulated sm^faces. New lesions appear from 
time to time upon the neck following the line of the 
hairs, or the disease encroaches upon the hairy scalp, 
and in the course of months or years it may reach 
even up to the vertex. "When these lobulated masses 
attain a certain size they often become softened a lit- 
tle, and when cut may be found to contain pus. At 
times they secrete a foul-smelling fluid, and become 
crusted. "When the papules run together the inflam- 
matory halo disappears. Gradually the growths be- 
come sclerosed and assume a keloidal appearance. 
When the hairy scalp is attacked, pustules may form 
out of w^hich little bundles of hair protrude; but the 
hair is not loosened. The keloidal masses are generally 
bald; but some have a few bundles or tufts of hair in 
them, which usually is firmly seated and resistant to 



DERMATITIS PAPILLARIS CAPILLlTII. 81 1 

attempts at epilation. Sometimes these tufts are ap- 
parently only mechanically held in the furrows of the 
growths and are readily pulled out. Sometimes the 
hair when pulled appears healthy; sometimes atro- 
phied; sometimes it breaks upon slight traction. 

The disease may give rise to some tenderness or may 
be absolutely painful. Sometimes there are no sub- 
jective symptoms, and the patient will complain only 
of the deformity and the inconvenience. The course 
of the malady is exceedingly slow, but steadily pro- 
gressive. 

Etiology. — The etiology of the disease is very ob- 
scure. From its location at the back of the neck, at 
about the place where the band of the shirt or other 
clothing rubs, it has been suggested that the rubbing 
of the shirt-collar may be an etiological factor. It oc- 
curs both in women and men, and may begin at any 
age. 

Pathology — The disease process is described by 
Kaposi as a chronic inflammation of the chorion prin- 
cipally, attended by a great increase in the number of 
the blood-vessels and in the size of the papillae. This 
is followed by the formation of new connective tissue, 
which by pressure destroys the sweat and sebaceous 
glands, and finally compromises the existence of the 
hair-follicles, and the hair itself. 

Diagnosis. — The peculiar location of this disease 
upon the back of the neck at the margin of the hair, 
the arrangement of the hair in little tufts in the keloidal 
masses, and the great hardness of the lobulated or 
papillomatous tumors, distinguish this malady from 
all others. In sycosis we have no hard tumors, 
and the hairs are surrounded by pustules; in our pre- 
sent disease the pustules that may be present either 
have no relation to the hairs, or else surround a number 
of them. Warts ot papiUomas ot the scalp lack the 



S12 DISEASES OF THE HAIR AND SCALP. 

hardness of dermatitis papillaris capillitii, do not oc- 
cupy the same region, do not tend to increase in size, 
and do not take on a keloidal condition. The large 
uneven tumors of mykosis fungo'ide resemble the 
growths of dermatitis papillaris capillitii, but they 
are not quite so soft; they are more generally distribu- 
ted over the v^hole body, come and go in a capricious 
manner, often break down and ulcerate, and do not 
slowly change into keloidal tumors or streaks. 

Prognosis. — So far as reported the growths are be- 
nign and are compatible with a good state of health. 
But they do not yield readily to treatment, and left to 
themselves are progressive, and show no tendency to 
spontaneous recovery. 

Treatment. — The best treatment is the most radi- 
cal, that is to scrape out the small growths with the 
sharp spoon, to cut off the longer small ones with the 
scissors, and to excise the large ones. In any case, 
care must be used to get down to the true skin and to 
remove the whole growth. After removal by any 
means the base should be cauterised, and for this pur- 
pose we may use the nitrate of silver stick, which both 
cauterises and stops the sometimes not insignificant 
bleeding following the operation. In some cases the 
stronger caustics may be employed with benefit with- 
out operation. Hebra, Jr., (16) speaks higlily of the 
galvano-cautery in this disease, and has found that it 
was as effectual in removing the growths, and more 
active in preventing their retiu^n, than any other oper- 
ative procedure. 



OHAPTEE XXIY. 

N^VUS PILOSUS. 

Hair-moles or birth-marks are usually congenital, 
and even in cases in which they have developed within 
a few years after birth, the hair grows upon a con- 
genitally hyperpigmented surface, a pigmentary 




mole. They are of all sizes from that of a split pea 
up to that of a huge patch big enough to involve the 
surface of the body from a Hue between the angles of 
the scapulae to half way down the thigh. They may 



314 DISEASES OF THE HAIR AND SCALP. 

be unilateral or bilateral, and sometimes symmetrical. 
There may be only one of them, or there may be scores 
of them; and they may be located on any region of 
the body. It is when they are located on the face or 
arms that they come most often under our observa- 
tion. 

Wherever they are located, and whatever their size 
may be, they possess the same characteristics, namely: 
upon a thickened and pigmented patch of skin, usually 
of dark brown or black color, there is a more or less lux- 
uriant growth of dark stiff hair, and the whole patch is 
slightly raised above the level of the skin, and, if 
large, its surface is more or less uneven. The color 
of the patch varies with the complexion of the individ- 
ual, being light brown in blondes, and dark brown or 
black in brunettes. The hair is nearly always dai^ker 
upon these moles than it is on the head of the same 
person, excepting when the latter is black. The 
amount of hair present varies exceedingly; sometimes 
it is very luxuriant and grows close hke the fur of an 
animal; sometimes there are only a few stiff hairs in 
the mole. The thick growth is seen more often on the 
large moles; while the sparse growth is more common 
on the small moles, as on the face. These hairs are 
coarser than those on the head; even when a hairy 
naevus occurs upon the scali^, the hairs coveidng it will 
be coarser than those about it Exceptionally the hairs 
are fine. Pigmentary moles may or may not coexist 
with these hairy moles; molluscum fibrosum has been 
met with in several cases. 

Most of the cases reported as ' ^ circumscribed hyper- 
trichosis " are examples of hairy naevi. Some of these 
have been given in our chapter on Hypertrophia Pilo- 
rum ; sometimes these moles undergo a change into 
epithehoma. 

The etiology of nsevus pilosus is obscure; our only 



- N^VUS PILOSUS. 315 

supposition is that they are due to some nervous influ- 
ence. At times they occur along the course of nerves, 
and cases of extensive hairy moles of the back and 
thighs are not infrequently associated with spina bifida. 
They are sometimes hereditary, and I have seen them 
on the face in a number of cases of facial hirsuties. 
The popular idea that they are due to maternal impres- 
sions received during pregnancy is supported by not a 
few instances in ancient and modern times. 

Bull (635) in 1882 reported the case of a child with an 
extensive hair-mole whose mother was frightened by 
a dog in the third month of pregnancy; and Sommer 
(640), in 1885, described another case with the history 
of the mother having been frightened by a bear. How 
far maternal impressions really influenced these and 
other similar cases is not for me to determine. 

Histologically these growths consist of a slight hy- 
pertrophy of the papillary layer of the skin, with a de- 
posit of brown and black pigment granules in the rete 
mucosum. Morris (24.) The hairs are hypertrophied; 
the large hair-follicles are close together and possess 
small accessory hair-follicles in which are developed 
hairs; and there is a more rapid fall and new growth 
in them than in the skin of normal hairy parts. 
(MiCHELSON, (40), in Ziemssen.) 

The diagnosis of hairy moles from circumscribed 
hirsuties is determined by the presence of pigmenta- 
tion and thickening of the skin in the former, and 
their absence in the latter. 

Treatment. — The best treatment of hairy moles is 
electrolysis, practised as taught in our chapter on Hy- 
pertrophia Pilorum. This is an exceedingly biilliant 
operation in the small naevi of the face, not only des- 
troying the hair but also removing the discoloration. 
In large naevi it will certainly destroy the hair, and if 
any discoloration remains, it may be readily gotten lid 



316 DISEASES OF THE HAIR AND SCALP. 

of by the careful application of nitric or acetic acid, 
or the hke. Of course it is possible to remove the growths 
by the knife or by powerful caustics, but electrolysis is 
a less painful method, and if done with sufficient care it 
will leave scarcely any scar. 



CHAPTEE XXY. 

SYPHILIS— LUPUS— VITILIGO. 

These three diseases affect the scalp, either as part 
of a general eruption, or as limited to that region, 
alone. When occurring upon the scalp, their etiology 
and pathology are the same as when upon other regions. 
Their symptoms differ slightly from those seen on non- 
hairy parts, and in this chapter will be noted only such 
variations. 

Syphilis. 

The erythematous, papular, pustular, tubercular and 
gummatous forms of syphilis are met with on the scalp; 
while the squamous, bullous, vesicular, and pigmentary 
forms are not met with there. When syphilis attacks 
hairy parts it tends to assume the pustular form, the 
pustules forming about the hair-follicles; and this holds 
true during the whole of the active stage of the dis- 
ease, or what has been named the secondary period, 
whether the eruption upon the trunk and extremities 
be erythematous, papular, or pustular. Thus Basse- 
re au (1), found, in 153 cases of erythematous syphilis, 
the scalp affected with a 

Pustular eruption, . , .106 times 
Pityriasis, . . . . 13 '* 

Papular eruption, . • . 4 ^* 

Macular " . . . . 2 " 
No eruption, . . . . 28 '' 

Erythematous syphilis of the scalp does occur, 
however, witia macu-es alone, wIuqU hero as elst^whei*^ 



31 S DISSA3ES OF THE HAIR AND SCALP. 

are round or oval, rosy or red spots, out of which the 
red color may be driven by pressure. They cause the 
patient no annoyance, and he would be ignorant of 
their presence were it not that at this time there is of- 
ten some seborrhoea, and the accumulation of sebaceous 
matter about the mouths of the hair-follicles forms 
little crusts upon which the comb catches in combing 
the hair. Pustules located about the hair-foUicles are 
associated very often with the macules, and the little 
scales they form in drying aid in producing that symp- 
tom of ' ' catching of the comb ' ' which is one of the 
diagnostic marks of syphilis. The macular syphihde 
of the scalp is rare, and is met with most often along 
the margin of the hair upon the forehead and occiput. 
If it is accompanied by a good deal of seborrhoea we 
may have a marked fall of the hair and alopecia. 

The Papular SYPHiLmE is seen upon the scalp more 
commonly than the macular syphilide. It is often ac- 
companied by pustular syphilides, and by seborrhoea, 
and is sometimes itchy. Its most frequent site is 
along the margin of the hair, and the papules may be 
either smaU or large. The small papular syphilide is 
round and slightly elevated above the surface; red in 
color at first, afterwards becoming coppery or raw 
ham colored; in close relation to the hairs; and some- 
times a little scaly. It becomes absorbed after some 
weeks' duration, and as it disappears the hair falls out. 
The alopecia is only partial and transient, and the hair 
soon grows again. The large papmlar syphilide is of 
greater diameter and more elevated than the preced- 
ing variety. Like it, it is scaly, and when it becomes 
absorbed the hair falls. This syphilide sometimes 
ulcerates and heals with a cicatrix. Sometimes the 
papules become greatly hypertrophied, and run together 
to form raspberry-formed masses to which the name 
of " f ramboesoid, " vegetative, or verrucous syphilide 



SYPHILIS— LUPUS— VITILIGO. 319 

has been applied. Each mass is formed of a number of 
hypertrophied papules and resembles the papillomatous 
formation of a wart. It is round, of varying size, and 
gives vent to a foul-smelling secretion; its surface is 
sometimes moist and sometimes crusted, and when the 
crust is removed a shallow ulcer is uncovered. These 
masses may be present in great numbers so as to involve 
a large part of the scalp. They at last become absorbed 
or break down, and always leave permanent baldness. 
The Pustular syphilide is very common upon 
the scalp, and probably occurs in every case of syph- 
ilis with cutanous manifestations. It is seen very 
early in the disease with the erythematous eruption; oc- 
curs also with the papular eruption; it may be part of 
a general pustular eruption, or may occur as a local- 
ized and relapsing syphilide. The pustules are either 
scattered, or grouped in circles or segments of circles, 
and usually occur about the hair- follicles. They may 
be small and superficial, or large, deep and ulcerating; 
and are surmounted by a greenish or blackish crust 
varying in size, thickness and color. The small super- 
ficial and pustular syphilide of the scalp, the acne- form 
syphilide, is seen usually within the first six 
months of the disease, but it may relapse and appear 
later. It is a papulo-pustular lesion, the papule appear- 
ing first and the pustule slowly forming on top of ijb. 
The pustule is conical or slightly rounded in form, and 
of pin -head size, or slightly larger. The pustule soon 
opens and discharges its contents, which dries into the 
characteristic greenish crust of syphilis. This syphilide 
is often very slow in its course, especially when it oc- 
curs as a part of a general specific pustular eruption, and 
on healing leaves a small cicatrix. The hair falls out 
of the follicles in relation with the pustules, but new 
hair grows again, excepting in cases in which the dis- 
ease ha^ been more ^evex'^ than usual, so tho-t the deep 



320 DISEASES OF THE HAIR AND SCALP. 

parts of the hair- follicles have been destroyed. The 
pustular syphilide may be in the form of lesions which 
are pustules from the beginning and tend to run to- 
gether and form patches. This is known as the im- 
petigo-foi^m syphilide. The patches are covered with 
greenish or blackish thick crusts; are evidently made 
up by the coalescence of several pustules; and when 
the crusts are removed an ulcerating surface is ex- 
posed. The ulceration may be superficial or deep, and 
in debihtated subjects it may become serpiginous. This 
form of pustular syphilide occurs later than the acne- 
form syphihde, usually after the first six months; it 
may be met with in the second or third year of the 
disease. Sometimes it is apparently the form in which 
the acne form of syphilide relapses. Its course is slow; 
it always heals by cicatrization; and is always followed 
by permanent baldness. 

The third and last form assumed by the pustular 
syphilide on the scalp is called the ecthyma-form 
syphilide. This syphilide may occur during the second 
half of the first year, or be one of the late or tertiary 
manifestations of the disease. Occurring early in the 
disease the pustules may be very numerous, and tend 
to group; occurring late in the disease there are but 
few of them, and these are grouped in circles or seg- 
ments of circles. The pustules are larger than the 
other pustular syphilides, rapidly become ulcers; and 
are covered soon with a thick greenish or brownish 
crust. These lesions are usually superficial in the 
early period of the disease; deep and often serpiginous 
when occurring as a late lesion. The ulcers heal by 
cicatrisation and leave a bald spot. 

The Tubercular syphilide is one of the late forms 
of syphilis, and occurs sometimes upon the scalp, either 
alone or in connection with the same lesion elsewhere 
upon the body. They begin as deep red spots, which 



SYPHILIS— LUPUS— VITILIGO. 321 

increase in size and become elevated. They are from 
a half to one inch in diameter; tend to group in circles 
or segments of circles; are sometimes surmounted with 
a scale; sometimes ulcerate and become serpiginous; 
and sometimes become verrucous, and assume that 
framboesoid character described under the papular 
syphilide. Whether ulcerating or not they leave a 
cicatricial spot behind them, and this is absolutely 
bald. This lesion is prone to relapse, so that at times 
a large part of the scalp becomes bald. 

The Gummatous syphilide is not very common on 
the scalp. There may be only one gumma, or there 
may be a number of them. Small ulcerations fre- 
quently take place about the hair- follicles, so that the 
whole gummatous mass is covered with ulcers. The 
gumma is either absorbed or breaks down and ulcer- 
ates, and then the bones of the skull may be more or 
less damaged. It occurs most frequently upon the 
frontal and parietal region, and causes permanent 
baldness. Though these syphilides have been described 
here as affecting the scalp, they occur quite commonly 
on all the other hairy regions and then present similar 
symptoms. Erysipelas may complicate syphihs of the 
scalp. 

The diagnosis of the early syphilides is unattended, 
as a rule, with difficulty, other unmistakable symptoms 
of constitutional syphilis being present upon the general 
integument. It is probable that unless they cause 
baldness they are frequently overlooked. When ques- 
tioning a patient, with some doubtful skin lesion, as to 
his having had syphilis, the two most important facts to 
ascertain in regard to the scalp are the occurrence of 
baldness in patches coming on suddenly; and the 
catching of the comb upon the little scales on the 
scalp. Sometimes the later lesions offer considerable 
difficulty in diagnosis, and we are called upon to deter- 
31 



B2^ DISEASES OF THE HAlR AND SCALP. 

mine whether a pustular eruption is an eczema, simple 
impetigo, or non-specific ecthyma, or a syphilide; or 
we may have to decide whether a given lesion is lupus 
or an ulcerating tubercular syphihde. The gumma 
resembles a kerion; and a papular syphihde may be 
mistaken for psoriasis. 

From eczema or simple impetigo a pustular syphihde 
is differentiated by the history of the initial lesion and 
preceding specific eruptions; by the greater slowness 
of the development of the pustules, and their not 
breaking down readily; by the absence of itching and 
burning; by the greenish or blackish crusts; by the 
little cicatrices left by the pustules; and by the baldness 
it causes. 

From non-specific ecthyma, the specific form may 
be known by the history of other specific lesions; by 
the grouping of its pustules and their slower course, by 
the ulcers they form, which are often serpiginous, 
always have abrupt edges, and are deep, with their 
floors covered with a thick puriform fluid; by the 
crusts being thicker and more heaped up; and by the 
smooth, white, bald cicatrices they leave. 

From lupus, the ulcerating tubercular- syphihde 
differs in occurring upon the scalp alone at times, 
while lupus vulgaris never occurs there without being 
found elsewhere upon the face or extremities; in 
syphihs there is an entire absence of the characteristic 
brownish nodules or papules of lupus. Syphilitic 
ulcers are rounded, often serpiginous, always punched 
out and deep, are covered with thick, heaped-up green- 
ish or blackish crusts, and heal by a smooth, white, 
non-deforming cicatrix. Lupus ulcers are more ir- 
regular in shape, their crusts are thinner, and they 
heal, if at all, with more or less puckered and unsightly 
cicatrices. Syphilis is a disease of adult or advanced 



SYPIIiLlS— LUPUS — ViTILIG . 32 .^ 

age, while lupus is a disease that begins most often in 
childhood. 

The history and course of kerion is entirely different 
from that of a gummatous syphilide, as it occurs in 
childhood, is usually a single lesion, forms rapidly, is 
painful and tender, and most often stands in some re- 
lation to trichophytosis capitis. A gumma has a 
marked tendency to break down and ulcerate, whereas 
kerion has no such disposition. 

Psoriasis may readily be distinguished from a papu- 
lar syphilide in groups by the fact that it never occurs 
on the scalp alone. It is, moreover, very decidedly 
scaly when upon the scalp, while the syphilide is not 
scaly though it may be crusted. Psoriasis causes 
neither cicatrices nor baldness; syphilis gives rise to 
both. 

It is possible that an epithelial cancer may be mis- 
taken for an ulcerating syphilide; but its hard, waxy 
and raised edge, with delicate blood-vessels running 
over it; its much slower course; the shooting pains 
that accompany it; the great proneness to bleeding 
that it evinces; and the fact that it is uninfluenced by 
antisyphilitic remedies, sufficiently establish its diag- 
nosis. 

The TREATMENT of the syphilides of hairy parts is 
the same as that of the same lesions located elsewhere. 
Internally mercury is indicated for the early lesions; 
mercury with or without the iodide of potassium for 
the intermediary or late lesions; the iodide of potas- 
sium in increasing doses and pushed rapidly until the 
nose runs and the eyes water, in the ulcerating lesions. 
These drugs, combined with tonics as needed, and the 
enforcement of the laws of hygiene, will enable us to 
effect a cure of the disease in most cases even without 
local treatment. Local treatment is demanded to 
combat certain symptoms and to hasten the disappear- 



Sf^4 DISEASES OF TliE HAIR AND SCALP. 

ance of the lesions. The early syphilides usually do 
not requh^e treatment. If the scalp is covered with 
scabs and crusts they should be removed with soap 
and water, and an ointment of the white precipitate of 
mercury with or without vaseline, or of the nitrate of 
mercury in the strength of one or two drachm.s to the 
ounce of vasehne, may be applied. If there are super- 
ficial ulcerations, the same ointments may be used; 
and if the ulcers are deep, iodoform in powder wiU 
form a good dressing. The treatment of alopecia re- 
sulting from S3^phihs has been given already in our 
chapter on Alopecia. 

Lupus Vulgaris. 

This never occurs primarily upon the scalp. When 
seen in this region it is usually an extension from the 
forehead, and presents but a single patch. It then, 
according to Hans von Hebra (16), takes the form of a 
flat, httle elevated, even infiltration of the skin which 
slowly proceeds to ulcerate. The hairs may grow 
with scarcely impaired vigor for some time after the 
disease has mvaded the scalp. The disease is steadily 
progressive, heals with cicatricial tissue in one place 
while spreading in another, and in the course of years 
may involve the whole scalp, converting it into a mass 
of puckered cicatrix, which of course is without hair. 

The DIAGNOSIS and treatment of the disease as it 
affects the hairy parts is the same as when it attacks 
other parts, and for this the reader is referred to the 
text-books of dermatology. 

Lupus Erythematosus. 

This disease which originates in the hair-foUicles 
and the sebaceous and sweat-glands of the skin is not 
infrequently met with on the scalp and hairy parts of 
the body. The scalp may be invaded from a j)atch 



SYPHILIS—LUPUS— VITILiaO. 325 

upon the face, or occur coincidently with the disease 
on the nose, cheeks or other parts. It begins in one 
or a number of round red spots situated about the hair- 
foUicles. These increase in size, and new spots appear- 
ing, they at last coalesce to form a patch, which is ir- 
regular in shape and of various sizes up to one large 
enough to involve the greater part of the scalp. A 
fully formed patch is of red or violaceous color, covered 
with closely adherent thin, parch m3nt like scales, 
which are attached to the follicles of the scalp; sharp 
in outline, always dry, and having its centre formed 
of dehcate cicatricial tissue. Eventually cicatrization 
will take place in the whole patch, and the part will 
become absolutely and permanently bald. The disease 
is slow and chronic in its course, and at times is at- 
tended with burning or itching. 

The DIAGNOSIS of the disease is easy. It is most apt 
to be confounded with ringworm and psoriasis. Ring- 
worm differs from it in having a history of contagion, 
in its rounded shape, in its abundant scales and crusts, 
in its broken off and diseased hairs, and in its sponta- 
neous recovery without leaving a cicatrix or baldness. 
Psoriasis is distinguished by having characteristic 
patches upon other parts of the body, by its more 
abundant scaling, by its not affecting the hair, by its 
history of recovery and relapses, and by its leaving no 
cicatrix. 

The TREATMENT of lupus erythematosus of the scalp 
is the same as that of the same disease on other parts. 
I would here only lay special stress upon the great 
value of the local application of pure carbolic acid, a 
plan of treatment proposed by Dr. Geo. H. Fox, of 
New York, and one that is attended with wonderful 
results in many cases. The" acid is to be carefully ap- 
plied by means of a little cotton on a bit of wood, and 
the application repeated every week, or more often, 



S26 DISEASES OF THE HAIR A?lD SCALP. 

the frequency depending upon the fall of the crusts 
left by the previous burning. Phosphorus in the dose 
of -gV to 5V of a grain in pill form may be administered 
by the mouth at the same time, care being had to in- 
termit its use from time to time. 

Vitiligo. 

Leucoderma, acquired albinism, or vitiHgo often 
befalls the hair, and causes white patches or tufts of 
hair to appear among the darker hair of the part. 
The skin of the scalp beneath the tuft is perfectly 
healthy, and the only change either it or the hair suf- 
fers is the loss of color on account of a loss of pigment. 
There may be only a single patch of white hair, or there 
may be so many that the whole hair of the head is 
nearly white. The hair may be affected on any part 
of the body. The disease is unattended with symp- 
toms, and is chronic. Electricity in the form of gal- 
vanism or in the static form offers the only chance for 
improving the condition, but that chance is very small. 
Besides the diseases already described many other of 
the cutaneous diseases may occur upon hairy parts, but 
the situation in no wise affects the symptoms of such 
diseases, and therefore their consideration has not been 
included in this book. 



BIBLIOGRAPHY. 



Note. — References in the text (1, 2, 3, etc.), are to be found in 
the following list of bibliography and journal literature, under 
the corresponding numbers. 

A. Treatises upon the Skin and Syphilis. 

1. Bassereau. — Traits des Affections de la Peau, Paris, 1852. 

2. Bateman, Thos. — Synopsis of Cutaneous Diseases, London, 
1829. 

3. Behrend, Gf. — Lehrbuch der Hautkrankheiten, 2d Ed., Ber- 
lin, 188B. 

4. Bulkley, L. D.— Manual of the Diseases of the Skin, 2d Ed., 
New York, 1882. 

5. Bulkley, L. D. — Eczema and its Management, 2d Ed., New 
York, [1884]. 

6. Bumstead and Taylor. — Venereal Diseases, 2d Ed., Phila., 
1883. 

7. Coats, J.— Manual of Pathology, Phila., 1883. 

8. Deligny, L. — L'eczema, Paris, 1885. 

9. Diday and Doyon — Therap. des Mai. Cutan. et des Mai Yen., 
Paris, 1876. 

10. Duhring, L. A.— Diseases of the Skin, 2d Ed., Phila., 1881. 

11. Finger, E. — Die Syphilis und die venerischen Krankheiten, 
Wien, 1886. 

11a. Fournier. — Legons sur la Syphilis, Paris. 

12. Fox, T.— Skin Diseases, 3d Ed., New York, 1877. 

13. Green, J.— Diseases of the Skin, 2d Ed., Phila., 1859. 

14. Guibout, E. — Traite des Maladies de la Peau, Paris, 1885. 

15. von Hebra and Kaposi — Lehrbuch der Hautkrankheiten, 2d 
Ed., Stuttgart, 1876. 

16. von Hebra, H.— Die krankhaften Veranderungen der Haut, 
Braunschweig, 1884. j 

17. Hogg.— Parasitic Origin of Skin Diseases, London, 1873. 

18. Hyde, J. N.— Diseases of the Skin, Phila., 1883. 

19. Kaposi, M. — Pathologic und Therapie der Hautkrank- 
heiten, Wien, 1880. 

20. Leloir, H. — Recherchos sur les Affections Cutaneos, Paris, 
1882. 

21. Lesser, E. — Lehrbuch dor Haut und (Tcschlechtskrank- 
heiten, Leipzig, 1885. 

22. Liveing, R. — Treatment of Skin Diseases, 4th Ed, New 
York, 1878. 

23. Liveing, R. — Diagnosis of Skin Diseases, New- York, 18T9. 

24. Morris, M. — Manual of Skin Diseases, London, 1879. 



S^8 BlBLlOGRAPffl'. 

25. Morrow, P. A.— Venereal Memoranda, ISTew York, 1885. 

26. Neligan, J. M.— Diseases of the Skin, Philadelphia, 1852. 

27. Neumann, I.— Hautkrankheiten, 5th Ed., Wien. 1880. 

28. Otis, F. N. — SyphiUs and Genito-urinary Diseases, New 
York, 1886. 

29. Piffard, H. Gr. — Elementary Treatise on the Diseases of the 
Skin, New York, 1876. 

29a. Piffard, H. G.— Materia Medica and Therapeutics of the 
Skin, New York, 1881. 

30. Purdon— Cutaneous Medicine. 

31. Rayer — Maladies de la Peau, Paris. 

32. Ricord. — Lettres sur la Syphilis, Paris. 

38. Robinson, A. R. — Manual of Dermatology, New York, 1884. 

34. Schwimmer, E. — Die neuropathischen Dermatonosen, Wien, 
1888. 

34a. Squire, B. — In Reynold's System of Medicine, Vol. V., Lon- 
don, 1879. 
84b. Squire, B. — A Manual of the Diseases of the Skin. 

35. Van Buren and Keyes — Genito-urinary Diseases and Sy- 
philis, New York, 1877. 

36. Van Harlingen, A. — Hand-book of Skin Diseases, Phila, 1884. 

37. Wilson, E.— Diseases of the Skin, 4th Ed., London, 1857. 

38. Wilson, E. — Lectures on Eczema, London, 1870. 

39. von Zeissl — Pathology and Treatment of Syphilis, 2d Ed., 
New York, 1886. 

40. von Ziemssen, H. — Handbuch der Hautkrankheiten, Leip- 
zig, 1884. 

B. Treatises ox the Hair. 

41. Bartels, M. — Ueber abnorme Behaarung beim Menschen, 
Berhn, 1876. 

41a. Bazin, E. — Legonssurles Affections Parasitaire, Paris, 1862. 

42. Behrend, G. — Beitrag zur Pathogenese und Behandlung der 
Acme disseminata und der Sycosis, Berlin, 1881. 

43. Beigel, H. — Ueber Auftreibung und Bersten der Haare, 
Wien, 1855. 

44. Beigel, H.— The Human Hair, London, 1869. 

45. Bergeron, E. J. — £tude sur la Geographieet la Prophylaxie 
des Teignes, Paris, 1865. 

46. Besnier. — Parasitic Diseases of the Skin, Paris, 1884. 

47. BouUaud, C. H.— De la Trichophytie. These de Paris, 1865. 
No. 232. 

48. Cazenave, A. — Traite des Maladies du Cuir Chevelu, Paris, 
1850. 

49. Chausit — Sycosis ou Mentagre, Paris, 1859. 

50. Chevrier— Du Sycosis, These de Montpellier, 1871. 

51. Clasen, F. E.— Die Haut und das Haar, Stuttgart, 1886. 

52. Cottle, E. W. — The Hair in Health and Disease, London, 
1877. 

53. Courreges, A. — Etude sur la Pelade, Paris, 1874. 

53a. Davey, W. — Treatise upon the Human Hair, London, 1871. 

54. Eble, B. — Die Lehre von den Haaren, Wien, 1831. 

55. Ebner, V. v. — Mikroskopische Studien liber Wachsthum 
und AVechsel der Haare, 1876. 

56. Feiertag—Ueber die Bildung der Haare, Dorpat, 1875. 



BIBLIOGRAPHY. 329 

57. Feulard, H. — Tei^nes et teigneux, Paris, 1886. 

58. Fox, (ieo. H. — The use of Electricity in the Removal of 
Superfluous Hair, etc., Detroit, 1886. 

59. Gamberini — Le Malattie del Pele delle Unghie, Bologna, 
1882. 

60. Godfrey, B. — Diseases of the Hair, London, 1872. 

61. Grecesco— De I'Achorion Schoenleinii, These de Paris, 1868. 
No. 137. 

62. Hildebrandt, H. — Ueber abnorme Haarbildung beim Men- 
schen, Konigsberg, 1878. 

63. Hildesheim, W. — Das Haar und seine Krankheiten, Ber- 
lin, 1846. 

64. Leonard, C. H.— The Hair, Detroit, 1881. 

65. Leturc, A. — Le Nature et le Traitement dela Pelade, Paris, 
1878. 

66. Michelson, P. — Ueber Herpes tonsurans und Area Celsi, 
Leipzig, 1877. 

67. Morris, M.— The Management of the Skin and Hair, Lon- 
don, 1886. 

68. Oesterlen, O. — Das menschliche Haar und seine Gerichts- 
arztliche Bedeutung, Tubingen, 1874. 

69. Perry, B. C— The Human Hair and the Cutaneous Diseases 
which affect it, 2d. Ed., New York, 1866. 

70. Pfaff, E. R.— Das menschliche Haar, 2d Ed., Leipzig, 1869. 

71. Pincus, J. — Haarkrankheiten und Haarpflege, 2d Ed., 
Leipzig. 

72. — Pincus, J. — Der Einfluss des Haarpigments und des Mark- 
canals auf die Farbung des Haares, 1872. 

73. Pincus, J. P. — Das polarisirte Licht als Erkennungs-Mittel 
flir die Erregungs-Zustande der Nerven der Kopfhaut, Berlin, 
1886. 

74. Ranke, J. — Haarmenschen, in Allgemeine Naturkunde, 
Leipzig, 1886. 

75. Robinson, T. — On Baldness and Grayness, 2d Ed., London, 
1883. 

76. Rosenberg, H. — Der Weichselzopf, Mtinchen, 1839. 

77. Rouquayrol, E. — Prophylaxie et Traitement de la Teigne 
tondante, Paris, 1879. 

78. Schultz, H.— Haut, Haareund Nagel, 3d Ed., Leipzig, 1885. 
78a. Sexton, Geo. — The Hair and Beard, and Diseases of tlie 

Skin, London, 1858. 

79. Smith, Alder. —Ringworm, its Diagnosis and Treatment, 3d 
Ed., London, 1885. 

80. von Steinkiihl, W. — Der Weichselzopf in Deutscliland, Had- 
amar, 1817. 

81. Tobolewski, F. R. — Kurze Uebersieht iiber Bau, Zweck, 
und Krankheiten derHaare, Leipzig, 1884. 

82. Truefit, H. P.— New Views on Baldness, London, 1863. 

82a. Unna, P. G. — Anatomie und Physiologie de Haut, in 
Ziemssen's Handbuch de Hautkrankheiteii, 1884. 

83. Waldeyer, W. — Atlas der Menschlichen und Tierisehen 

Haare, Lahr, 184. 

84. Wilson, E.— Healthy Skin, 8th Ed., London, 1876. 

Andoque, A.— I.a Phvsioloivie dos Cheveux, etc., Paris, 1870. 
Anonymous— The Art of Preserving the Hair, London, 18.^5. 
Boeck, F.— Area Celsi. Greifswald, 1807. 
Praijustein, H,— Alopecia Areata als Trophoneuroseu, Freiburg, 1S73, 



odO CIBLIOGRAPHY. 

Chevalier, Sarah A.— A Treatise on the Structure of the Human Hair, Ntw 
York, 1868. 

Couillebault, L.— Quelques Considerations sur T Herpes Parasltai re dans les 
Paj-s Chauds et Traitemeut par le Cassia Alata, Paris, 1886. 

Debay- -Hygiene complete des Cheveux et de la Barbe, Paris, 1851. 

Deville, F.— Theoretical and Practical Exposition of the Diseases of the 
Hair, Baltimore, 1849. 

Ecker, A. — Ueber abnorme Behaarung des Menschen, 1878. 

Jahn, G. W.— Der Haararzt, Prag. 1828. 

Kneiphof, J. G.— Abhandlung von Haare, 1777. 

Ledeganck— Pathologie des Maladies des Follicules Pileux et Sebac6es, 
Bruxelles, 1872. 

Lovet, H. T.— Treatise on the Human Hair, New York, 1851. 

Merkel, J. F.— Der erfahrene Haararzt, Leipzig, 1840. 

Obert— Traite complete des Maladies des Cheveux, etc., Paris, 1848. 

Reissner— Beitrage zur Kenntnis der Haare des Menchen iind der Tiere, 
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Rowland—The Human Hair, 1853. 

Schweninger, E. —Ueber Transplantation und Implantation von Haaren, 
Miincheu, 1875. 

Voigt, C. A.— Abhandlxmg iiber der Richtung der Haare, 1859. 

"Wilson, E.— Rmgworra, London, 1847. 

C. Journal Literature. 

85. Arnstem — Die Nerven der behaarten Haut, Wien. Akadem,, 
Sitzungsbr. 1876. Ixxiv. 1. (Abst. Yrtljschr f. Dermat. und Syph. 
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85a. Cottle, A. — Practical Remarks on some Points of Tricopa- 
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86. V. Ebner. — Mikroskopische Studien iiber das Wachsthum 
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339. 

87. Esoff, Johannes — Beitrag zur Lehre von der Icthyosis und 
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88. Fleming W. — Ein Drillingsliaar mit gemeinsamer innerer 
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89. Flescli, M. — Locken von gekrauselten Haar inmitten der 
sonst schlichten Kopfhaares. Vrhndl. der Berliner Anthrop. 
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90. Jobert — Des Polls consideres comme Agents tactiles chez 
THomme, Graz. Med. de Paris, 1875, iii, 74. 

91. Lewis, W. J. — Hair microscopically examined and medico- 
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92. Lowther, T. D. — Does the Hair grow after Death ? Louis- 
ville Med. News, 1877, iv. 186. 

93. Pincus, J. — Der Einfiuss des Haarpigments und des Mark- 
canals auf die Farbung des Haares, Archv f. Derm. u. Syph. 1872, 
iv. 1. 

94. Scnulin — Beitrage zur Histologie der Haare, Zeitschr. f. 
Anat. und Entwcklngs. gsch. 1877, ii. 654. Abst. Vrtljschr. f. Derm, 
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95. Wertheim, Gr. — Ueber den Bau des Haarbalges beim Men- 
schen, Wien. Akad. Sitzungsbr. Math, naturw kl. 1864, i. 302. 

Abst. Schmidt's Jahrbuch, 1865, cxvii. 286. 

Champuis & Moleschott— Untrsuch. z. Naturl. d. Mensch. u. d'Thiere, 1860, 
vii. 325. 

Gotte-Cntrlbl. f. d. Med. Wissensch. 1867, v. 769 ; also, Archv. f. Mikro. 
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Hodgkinson & Sorby— J. Chem. Soc. Lond. 1877, xxxi. 427. 

Pincus, J.— Archv. f. Anat. Phvs. u. Wissenschft. Med. 1871, pg. 55. 

Renaut. J.— Compt. rend. Acad. d. Sc. Par. 1880, xci. 1084. 

Schweninger, E.— Ztschr. f. biol. Miinchen, 1875, xi. 341. 

gtieda, L.— Archv. f . Anat. Phys. u. Wissensch, Med, 1867, pg. 5Ui 



BIBLIOGRAPHY. 661 

Canities. 

96. Anonymous — Periodic Change of Color of Hair, Lancet, 1884, 
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97. Berger, O. — Zwei Falle von Canities praematura, Virchow's 
Archiv. 1871, liii. 533. 

98. Brown- Sequard — Experiences demontrant que les Polls 
peuvent passer rapidenient du Noir au Blanc. Archv. d. Phys. 
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99. Charcot, J. M. — Apropos d'un Cas de Canitie survenue tres 
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100. Ehrmann, S. — Ueber das Ergrauen der Haare und ver- 
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101. Ehrmann, S. — Untersuchungen liber die Physiologie und 
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102. Ferguson, J. — Sudden Canities, Canad. Jour. Med. Sc. 1882, 
vii. 113. 

103. Godlee— Hereditary White Patch of Hair, Med. Times & 
Gaz. 1884, i. 180. 

104. Isdell, V. C. — Case of the Restoration of the Natural Color 
of Human Hair after having been Gray for several Years, Med. 
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105. Jackson, Geo. T. — Canities, Jour. Cutan. & Ven. Dis, 1885, 
iii. 38. 

106. Jeffries — Case of sudden Canities, Boston Med. & Surg. 
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107. Landesberg, M. — Jaborandi and Pilocarpine, Med. Bui. 
Philadelphia, 1882, iv. 43. 

108. Landois, L. — Das plotzliche Ergrauen der Haupthaare, 
Yirchow's Archiv. 1866, xxxv. 575. 

109. Landois, L. — E. Wilson^s Fall von Intermittenden Ergrauen 
der Haupthaare, Virchow's Archiv. 1869, xlv. 113. 

110. Lesser — Ueber Ringelhaare, Allg. Wien. Med. Zeit. 1885, 
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111. Miner, J. F.— Change of the Color of the Hair in a Night.— 
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112. Murray— Hair Bleaching from Neuralgia, Lancet, 1869, i. 
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113. Pincus, J. — Ueber Canities senilis und prematura, Vir- 
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115. Pohlmann, J. — An experimental study on the action of 
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116. Ravmond — Un Cas de Decoloration rapide de la Chevelure, 
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117. Shaw, H.— On Degradation of Type in the Insane, St. Barth. 
Hosp. Rep. 1884, xx. 169. 

118. Smythe, A. G.— Changing of the Color of the Hair without 
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119. Wallenberg— Ein Fall von bleibender VeWinderung des 
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und Syph. 1876, i. 63, • • 



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120. Welch, F. H.— On Change of Color in Hair, Lancet, 1873, 1. 
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121. "Wertheim, G. — Ueber das Ergrauen, Weisswerden und 
Ausfallen der Haare beim Menschen, Wien. Med. Wochschr. 1878, 
xxviii. 181 et seq. 

122. Wilson, E.— Ringed Hair, Trans. Roy. Soc. Lond. 1867. 

Discoloration of the Hair. 

123. Beigel, H. — Blaue Haare, Virchow's Archv. 1867, xxxviii. 
324. 

124. Billi — Un Caso di Tricolorosi, Gior. Ital. d. mal d. Pelle, 
1872, xiii. 243. (abst.) Ann. d. Derm, et Syph. 1872-'73, iv. 138. 

125. Cattell, Thos. — Practical Remarks on some Points of Tri- 
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cet, 1846, ii. 9. 

126. Cattell, Thos. — Practical Remarks on Diseases manifested 
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127. Hauptmann — Rothwerden dunkler Haare einer Leiche bei 
der Verwesung, Virchow's Archiv, 1869, xlvi. 502. 

128. Jackson, Geo. T. — Discoloration of the Hair, Jour. Cutan. 
& Ven. Dis. 1884, ii. 173. 

129. Leonard, C. H.— The Hair, Detroit, 1881. 

130. Oesterlen, O. — Das menschliche Haar, Tubingen, 1874. 

131. Orsi — Criine Haare (abst.) Virchow's Jahresbericht, 1871, ii. 
523. 

132. Petri — Ueber die griine Farbung der Haare bei alteren 
Kupferarbeitern, Brl. Klin Wchnschft. 1881, 18, 762. 

133. Pfaff — Das menschliche Haar, Leipzig, 1869. 

134. Prentiss, D. W. — Remarkable Change of Color of the Hair, 
while under Treatment by Pilocarpine, Phila. Med. Times, 1881, 
xi. 609. 

135. Reinhard, C. — Ein Fall von periodischen Wechsel der 
Haarfarbe, Virchow's Archiv. 1884, xcv. 337. 

136. Smylv, W. J. — Sudden Change in Color of the Hair and 
Skin, Med. Press. & Circ. 1883, xxxv. 184. 

137. Squire, B. — An extremely rare Condition of the Hair, 
Lancet, 1881, ii. 74. 

Alopecia. 

139. Anonymous— The Prevention of Baldness, Med. Record, 
N. Y., 1886, xxix. 101. 

140. Barlow, Thos. — Alopecia m Congenital Syphilis. Lancet, 
1877, ii. 276. 

141. Bierbaum, J. — Alopecia Partialis, Jour. f. Kinderheil, 1863, 
xU. 167. 

142. Chinch ole, F. — De ia Nature parasitaire du Pityriasis 
Capitis et de FAlopecia Consecutive, Paris, 1874. 

143. Cattle, Thos. — Practical Remarks on Diseases manifested 
in the Hair, Lancet, 1846, ii. 316. 

144. Cattle, Thos. — Practical Remarks on some Points of Trico- 
pathy and the Chemical Pathology of the Human Hair Lancet, 
1846, ii. 9. 

145. Cockburn, J. B. — Syphilitic Alopecia treated with 3L<ee's 
^l^rcuri^l Vapor Bath, Lancet, 1867, i. 763, 



BIBLIOGRAPHY. 333 

146. Crisp, E. — General Alopecia with Microscopic Specimens of 
the Hair and Nails, Trans. Path. Soc. Lond., 1871, xxii. 305. 

147. Douet — Syphilis constitutionelle — Alopecie, Graz. de Hop. 
1864, xxxvii. 259. 

148. Dulaurier,A. B. — Syphilis constitutionelle— Alopecie, Guer- 
ison, Gaz. de Hop, 1864, xxxvii. 310. 

149. Eaton, V. G.— A Bald and Toothless Future, Popular Science 
Month., N. Y. 1886, xxix. 803. 

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399. Piffard, H. G-. — Calx Sulphurata and its Uses, Jour. Cutan. 
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400. Robinson, A. R.— Sycosis, N. Y. Med. Jour. Aug. & Sept. 
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406. Yemans, C. C— Sycosis, Mich. Med. News, 1880, iii. 124. 

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Trichophytosis Capitis. 

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412. Besnier — Observations upon Parasitic Diseases of the Skin, 
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417. Cottle, W.— The Treatment of Ringworm, Lancet, 1880, i. 
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S44: felBLIOGRAPaiT. 

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425. Elhot, Geo. T.— The Diseases of the Skin caused by the 
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426. Fayrer, J. — Indian Ringworm and its Treatment by Goa 
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427. Finny, J. M.— The Croton Oil Treatment of Tinea Ton- 
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428. Foulis, Jas. — The Treatment of Ringworm of the Scalp, 
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429. Fox, T.— Ringworm, Lancet, 1871, i. 412. 

430. Fox, T.— Ringworm in Schools, Lancet, 1872, i. 5. 

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432. Fox, T. — Alopecia Areata and Tinea Tonsurans, Med. 
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433. Fox, T. — On Ringworm of the Head and its Management, 
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434. Gee, Saml. — The Treatment of Tinea Tonsurans, Lancet, 
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435. Grawitz, P. — Ueber die Parasiten des Soors, des Favus und 
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437. Hillier— Notes on Skin Diseases, Med. Times & Gaz. 1867, 
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438. Hoggan, G. — Comparative Growth of the Fungi of Favus 
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439. Horand — L'herpes Tonsurant, Lyon Med. 1874, xvii. 34. 

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442a. Jackson, Geo. T. — The Chronic Contagious Diseases of 
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444. Jenner, Wm.— The Pathology and Treatment of the Dis- 
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Morris— Jour. Roy. Microscop. Soc. 1883, iii. 329, 



BIBLIOGRAPHY. 34:7 

Schilling:— Compend. Clin, del Mai. Cutan. Roma, 1877. 
Startin— Trans. Willan Sc. Lond. 1885, i. 92. 
Ziemssen — Greifswalder Med. Beitriige, 1864, ii. 99. 

Kerion. 

499. Atkinson, I. E. — On Kerion Celsi, a Variety of Tinea Ton- 
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500. Auspitz — Ueber das Sogenannte Kerion Celsi, Wien. Med. 
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501. Dubini, A. — Vespajo del Capillizio, Giorn Ital. del Mai. 
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502. Fox, T. — The Kerion of Celsus; a Phase of Tinea Tonsurans. 
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503. Majocchi — Ten Cases of Kerion Celsi, Graz. Med. di Roma, 
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Andronico, C— Bull. d. Sc. Med. di Bologna, 1886, xvii. 377. 

Trichophytosis Barbae. 

504. Anderson, McC. — On the Pathology of the so-called Sycosis 
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505. Anderson, McC. — Tinea Barbae, Lancet, 1879, ii. 485. 

506. Anonymous — Herpes Tonsurans Barbae, Allg. Wien. Med. 
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507. Bulkley, L. D. — Trichophytosis Barbae, Arch. Dermat. 
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508. Burton, J. — Treatment of Porrigo Decalvans, Med. Times 
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509. Cane, L. — Cases of Ringworm Treated by 01. Hydrarg. 
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510. Chevrier — Du Sycosis, These de Montpelier, 1871. 

511. Dunlop— Sycosis Menti Resembling a Malignant Tumor, 
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512. Fox, T. — Parasitic Sycosis, Lancet, 1873, ii. 141; also Med. 
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513. Gerlier— Sur TEpidemie Trichophytique de Ferney- Vol- 
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514. Hardy— Quelques Considerationes sur TEtiologie, la Nature 
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515. Ihle, M. — Beitrage zur Behandlung der Hautkrankheiten 
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516. Jamieson, W. A. — On Tinea Barbae, the so-called Parasitic 
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517. Jenner, Wm.— Mentagra, Med. Times & Gaz. 1857, ii. 650. 

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519. Kobner, H. and Michelson, P. — Ueber Parasitare Svcosis, 
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520. Lang, E. — Ueber eine Seltenere Form der Parasitaren Sy- 
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521. Lewin — Sykosis Parasitica, Charite Annal. 1874, i. 639; 
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522. Piffard, H. G.— Trichophytosis Barbae, lUus. Quart. Med, 
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348 BIBLIOGRAPHY. 

523. Ravogli, A. — Sykosis Parasitaria Barbae, Cinein. Lancet 
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524. de Silva Lima, J. C. — Goa Powder, Med. Times & Gaz. 
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525. Smith, A.— Tinea Sykosis, Brit. Med. Jour. 1880, ii. 536. 

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527. Anderson, T. McC. — Parasitic Affections of the Skin, Med. 
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528. Anderson, T. McC. — Tinea Favosa Epidermidis, communi- 
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529. Anonymous — De la Teigne Faveuse et de son Traitement 
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533. Aubert, P. — Role du Traumatisme dans FEtiologie de la 
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539. Charpy, A. — Du Favus Miliaire, Annal. Derm, et Syph. 
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540. Denslow, L. G. N. — The Parasitic Diseases of the Skin, 
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546. Gigard, G. — Sur une Epidemic de Teigne Faveuse s^vis- 
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BIBLIOGRAPHY. 349 

547. Grrecesco— De FAchorion Schoenleinii, These de Paris, 1868, 
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558. Knoche, J. P.— Favus, The Kansas City Med. Index, 1885, 
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560. Laillier — Maladies Contagieuses du cuir chevelu chez les 
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562. Morrow, P. A. — Report on a Case of Favus with Remarks 
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563. Neumann, I.— Zur Entwickelungsgeschichte des Achorion, 
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565. Prior, C. E. — The Treatment of Porrigo Favosa by Car- 
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566. Purdon, H. S. — The Treatment of Favus, Archiv. Derm. 
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567. Purser, J. M. — Observations Tending to Show the Identity 
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568. Quincke, H.— Ueber Favus, Montshft. f. prakt. Derm. 1885, 
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570. Remy, Chas. — Recherches sur FxVnatomie Microscopique 
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571. Reynolds, H. J.— Favus, Chicago Med. Jour. & Exam. 1886, 
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572. Sawicki— Treatment of Favus, Przeglod. lekarski Krakow- 
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350 BIBLIOGRAPHY. 

573. Seymour, W. W. — Kerosene as a Remedy for Favus, Bost. 
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574. Simon, Th. — Dermatologische Mittheilungen, Archiv. f. 
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576. Smith, W. G. — Cases of Favus from the Cat, with Histories 
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578. Squire, B. — Case of Favus Cured without Epilation, Tr. 
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579. Unna, P. G. — Mykologische Beitrage, Vrtljschr. f. Derm, 
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580. Unna, P. G.— Icthyol. Montshft. f. prakt. Derm. 1882, i. 
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585. Bertulus, E. — L'ecole Moderne et le Phthiriasis on Maladie 
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586. Bulkley, L. D.— Phthiriasis, Arch. Derm. New York, 1881, 
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587. Crane, A. — Chrisma as a Parasiticide, Lancet, 1881, ii. 76. 

588. Du2:uet — Les taches Bleues; leur Production Artificielle, 
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589. Gibier— Nouvelle fitude sur la Correlation qui existe entre 
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590. Hamal— Pediculosis Pubis, Med. Times & Gaz. 1857, ii. 482. 

591. Moursou, J. — Nouvelles Recherches sur TOrigine des 
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592. Ryding, Geo.— Pediculosis Pubis, Lancet, 1858, i. 621. 

Pediculosis Palpebrarum;. 

593. Ring, F. W.— Case of Phthiriasis Palpebrarum. Med. Rec. 
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594. Rosenmeyer, L. — Ueber Pediculosis Palpebrarum, Mtinch. 
Med. Wochnschrft. Mch. 2d, 1886, pg. 145. 

595. Stelwagon, H W.— A Case of Phthiriasis Palpebrarum, 
Arch. Derm. N. Y. 1881, vii. 301. 



BIBLIOGRAPHY. 351 

Beigel's Disease, etc. 

596. Behrend, G. — Ueber Knotenbildung am Haarschaft, Vir- 
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597. Duhring, L. A. — Unknown Ova upon Human Hair, Archv. 
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598. Eberth, C. J. — Untersuchungen iiber Bakterien, Virchow's 
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599. Martin, Aloys— Zeitschrft f. Rationelle Med. 1863, xiv. 357; 
Abst. B. & F. M. C. Rev. 1863, xxxi. 527. 

600. Pick — Ueber Dermatomykosis Palmellina, Allg. Wien. Med. 
Zeit. 1875, xx. 370. 

601. Thin, Geo.— Case of Parasitic Affection of Moustache, Lan- 
cet, Nov. 4th, 1882. 

Kuchenmeister— Oester. Ztschr. f. prakt. Heilk. 1867, xiii. 218. 

Dandruff. 

602. Boeck, C— Abst. Montshft. f. prakt. Derm. 1886, v. 90. 

603. Bizzozero — The Microphyten of the Normal Human Skin, 
Gaz. d. Hosp. 1884, No. 29; Abst. Vrtljschr. f. Derm. u. Syph. 
1884, xi. 523. 

604. Chincholle — De la Nature Parasitaire du Pityriasis Capitis 
et de I'Alopecie Consecutive, Paris, 1874. 

605. Duhring, L. A. — SeborrhcBa of the Scalp and Face, Med. 
Times, Phila. 1879-80, x. 34. 

606. Ferrari — Etiology of Pityriasis, Atti Acad. Gioencia di Sc. 
Natur. i Catania, vol. xviii. ; Abst. Montshft. f . prakt. Derm. 1886, 
v. 84. 

607. Fournier — Pityriasis Capitis, Jour, de Med. et de Chir. 
1886, Ivii. 63. 

608. Heitzmann, C. — On the Treatment of Seborrhoea, Trans. 
Int. Med. Cong. Phila. 1876, pg. 723. 

609. Jackson, Geo. T. — Dandruff; What it is and How to Cure 
it, Med. Rec. New York, 1884, xxv. 428. 

610. Manino Lorenzo — The Microsporon dispar of Yidal in Se- 
borrhoea, Giorn. Ital. d. Mai. Yen. Mch. & April, 1886; Abst. 
Vrtljschr. f. Derm. & Syph. 1886, xiii. 457. 

611. Morison, R. B. — A New Instrument for the Treatment of 
Seborrhoea and Eczema Capitis, Maryland Med. Jour. 1883, x. 
446. 

612. Oudemanns & Pekelharing — Saccharomyces Capillitii, ein 
Spaltpilz der Behaarten Kopfhaut, Tiydschrift voor Genees- 
kunde; also, Archv. Neerl. d. Sc. Exactes, 1886, xx. 404; Abst. 
Montshft. f. prakt. Derm. 1886, v. 323. 

613. Payne, J. F. — Microsporon Furfur in Pityriasis of Scalp, 
Brit. Med. Jour 1886, ii. 922. 

614. Pellizzari, C. — Microphytes of the Normal Human Skin 
and of Alopecia Areata, Bollettino del Soc. Tra. i. Cultori del Sc. 
Med. i, Siena; Abst. Vrtljschr. f. Derm. u. Syph. 1884, xi. 523. 

Plica Polonica. 

615. Beigel, H.— Specimen of Plica Polonica, Tr. Path. Soc. 
Lond. 1866, xvii. 418. 

616. Beigel, H.— The Second Case of Plica Polonica observed in 
England, Med. Times & Gaz. 1867, i. 509. 



352 BIBLIOGRAPHY. 

617. Diet! — Zur Streitfrage des Weichselzopfes, Wien. Med. 
Wochnshrft. 1863, xxx. 737. 

618. Hamburger — Ueber die Irrlehre von der Plica Polonica, 
Zeit. V. Klin. Med. 1861. 

619. Lessing, F.— Plica Polonica, Med. Times, Phila. 1882-83, 
xiii. 82. 

620. Le Page, J. T.— On Neuropathic Plica, Brit. Med. Jour. 

1884, 1. 160. 

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621a. Le Viseur — Zur Weichselzopff rage, Deutsche Klinik. 1861 , 
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622. Mettenheimer, C. — Zur Entstehungsgeschichte der Weich- 
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623. Pestonji, D. B. — On a Case of Neuropathic Plica, Lancet, 

1885, ii. 431. 

624. Urbanowicz — De la Plique Polonaise, Archv. Gen. de Med. 
1871, i. 215. 

Note. — For literature prior to 1839, see Rosenberg, Der Weich- 
selzopf. Miinchen, 1839, pg. 65. 

Dermatitis Papillaris Capillitil 

625. Baker, M.— Acne Keloid, Trans. Path. Soc. Lond. 1882, 
xxxiii. 367. 

626. Hebra, H., Jr. — Bericht von Hebra^s Klinik. in "VVien. fiir 
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627. Hervouet, H. — Note sur un Cas d'Hypertrophie Papilli- 
forme du cuir Chevelu, Annal. Derm, et Syph. 1883, iv. 421. 

628. Hyde, J. N.— A Chnical Study of Dermatitis Papillaris 
Capillitii, Jour. Cutan. & Ven. Dis. 1882, i. 33 et seq. 

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630. Sangster, A. — A Papillary Tumor of the Scalp, Trans. In- 
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Naevus Pilosus. 

633. Anonymous — Remarkable Case of Hairy Naevus, Lancet, 
1869, ii. 276. 

634. Baker, W. M. — On the Removal, by Operation, of a Hairy 
Mole occupying one-half the Forehead, Lancet, 1877, ii. 803. 

635. Bull, W. A.— Case of Diffused Superpigmented Mole of Ab- 
domen, Brit. Med. Jour. 1882, i. 304. 

636. Despres, A. — Heterotopic Pileuse Cutanee Congenitale; 
Naevus Pilosus occupant presque tout le Corps, Gaz. Hebdom. 
Par. 1874, xi. 244. 

637. Hildebrandt, H. — Ueber Abnorme Haarbildung beim 
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638. Lawson. Geo. — Epithelioma of Large Mole, Trans. Path. 
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639. Murray, Jno. — Extensive and Increasing Hair Mole in a 
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scripta, Virchow's Archiv. 1885, cii. 407. 



IE"DEX. 



PAGE 

Achorion Schoenleinii, the. .230 

Acne keloid 307 

Air in cortex 24, 41, 42 

Alopecia, varieties of 80 

" adnata 81 

" " symptoms — 81 

" " etiology 81 

" " pathology . . .81 

" " prognosis ... .82 

" treatment.... 82 

" senilis, symptoms. .. 82 

" " etiology 83 

" " pathology 84 

" " prognosis 84 

'* " treatment 84 

" prematura, idio- 

pathica 84 

" " symptoms. 84 
" " etiology. .. 85 
" " pathology. 87 
" " prognosis. 88 
" " treatment. 89 
" prematura symptom- 
atica 91 

" " symptoms ... .91 

*' " varieties 91 

" " etiology 95 

" "pathology 97 

*' " prognosis 99 

** " diagnosis 99 

'• " treatment. . . .100 

" " prophylaxis. .100 

" furfuracea 91 

" pityrodes 91 

" " symptoms. 91 

" syphilitica 93 

" " symptoms. 93 

" follicularis 95 

" areata 105 

symptoms . . .106 

etiology 108 

pathology 112 

diagnosis IIG 

prognosis 118 



PAGE 

Aiopecia areata treatment. . .118 
Anomalous color changes ... .79 

" hair changes. . . .141 
Arrectores pili 30, 49 

" " functions of. . .49 

Atrophia pilorum propria. ..124 

Barber's itch 215 

Bearded women 149 

Beethaar 38 

BeigeFs disease 258 

Bibliography 327 

Black hair 78 

Blepharitis ciliaris 299 

Blue hair 78 

Brushes, selection of 53 

Brushing^ proper mode of . . . .53 

Cacotrophia f olliculorum. . . .276 

Calotte, the 239 

Canities, congenital 63 

" acquired 63 

' ' recurrent 64 

" sudden 65 

" etiology of iiS 

* ' pathology; of 68 

treatment of 71 

Chignon fungus 258 

Color of hair, post-mortem 

change in 78 

" " altered by 

chemicals 78 

Combs, selection of 54 

Combing, proper mode of. . . .54 

Cortex of hair 23, 41 

Curling of hair, cause of 46 

Cuticle of hair 24. 41 

Dandruff, symptoms 265 

etiology 267 

pathology 268 

" diagnosis 268 

" treatment 270 

prognosis 274 



S54 



INDEX. 



Defluviuin capiUorum 94 

Depilatories 159 

Dermatomykosis palm ellina. 260 
Dermatitis'^ papillaris capillitii 

307 
symptoms. 307 
etiology . . 211 
pathology. 211 
diagnosis. .311 
prognosis.. 312 
treatment. 312 
Diseases of the hair from ex- 
cessive sweating 259 

Distichiasis, symptoms 163 

' ' treatment 163 

Dressing the hair .55 

Duhring's case of parasitic 

disease 260 

Dyeing of hair 71 

Eczema axillae 301 

' ' barbae, symptoms . . . 294 
" " etiology 295 

296 
297 
297 
279 

280 
280 



" diagnosis... 
" prognosis . . 
" treatment., 
capitis, symptoms. . , 
" vesiculosum 
" pustolosum 
" erythemato- 

^ sum 

" squamosum 
*' etiology . . . . 
' ' diagnosis — 
' ' treatment . . 
prognosis... 



" palpebrarum 

" " symptoms. 

" " etiology . . . 

" " treatment . 

Electrolysis, operation by.. . 
Ethnological differences of 

hair 



,281 
281 
282 
,285 
288 
,294 
,301 
299 
299 
300 
300 
154 



,46 



False hair 55 

Favus, symptoms 225 

etiology 225 

pathology 230 

diagnosis 233 

prognosis 237 

treatment 238 

Felting of the hair 306 

FollicuUtis barbae 164 



PAGE 

Fragilitas crininm symptom- 
atica 124 

'' symptoms. ..124 

*' etiology 125 

treatment . . 125 

" idiopathica 125 

" symptoms. . .125 
pathology... 126 

etiology 127 

" treatment . . 127 

Granuloma trichophyticum .208 

Grayness 63 

Green hair 76 

Hair, general description of. . . 21 

medulla 22, 41 

varieties of 21 

blood supply of 29 

nerves of 29 

lymphatics of 29 

muscles of 30, 49 

embryonal change of . ..33 
puberal '' ..34 

growth of from centres .35 

shedding of 37 

matrices of 26 

root sheaths 27 

pigment 24,41, 42, 43 

color of 42 

life phenomena of 44 

rate of growth of 44 

average length of 44 

" number of 45 

diameter '' ... .45 

curliness of •. 46 

cuticle 24, 41 

ethnological difference 

of 46 

root 22, 24 

bulb 21 

shaft 21 

papilla 29 

follicle 26 

regeneration of 39 

microscopical appear- 
ances of 40 

hygroscopy of 46 

elasticity of 46 

electricity of 46 

physical peculiarities of. 46 
chemical constitution 

of 47 

uses of 47 

hygeine of 50 



im)Ex:. 



355 



Hair physiology of 31 

development in foetus. . .31 

point of 21 

cortex 23, 41 

cutting 56 

dyeing 71 

discoloration of 74 

splitting of 124 

moles 313 

Hats 55 

Henle^s layer 28, 29 

Henna 71 

Herpes tonsurans 181 

Hirsuties 143 

Homines pilosi 143 

Honeycomb ringworm 225 

Huxley's layer 28, 29 

Hypertrichosis 143 

" partial con- 
genital 147 

'* " ac- 
quired 148 

" transitory 150 

** universalis 143 

Hypertrophia pilorum symp- 
toms 143 

etiol- 
ogy 151 

" " treatment 154 

Keratosis pilaris 275 

" " symptoms . .275 

'* " etiology 276 

pathology ..276 

" " diagnosis ... 276 

treatment.. 277 

" " prognosis ... 278 

Kerion 209 

" symptoms 209 

" etiology 211 

" pathology 211 

" diagnosis 212 

" prognosis 213 

" treatment 213 

Lanugo hairs 21 

Lichen pilaris 275 

Lupus vulgaris 324 

" " symptoms 324 

" " diagnosis .... 324 

" " treatment . . . .324 

" erythematosus 324 

'* " symptoms. 324 

" *' diagnosis. .325 

** '* treatment.. 325 



PAGE 

Maculae cerulae 252, 254 

Medullary canal 22 

Microscopical examination of. 40 

' ' technique of 41 

Morbus Paxtonii 140 

Naevus pilosus 147, 313 

" " symptoms. . . .313 

" " etiology 314 

" pathology 315 

" " diagnosis 315 

'* " treatment. .. .315 

Night caps 56 

Noduli laqueati 141 

Paxton's disease 141 

Pediculosis capitis symptoms. 243 
" " etiology.. . 244 

" " pathology.. 245 

" " diagnosis . .247 

" " prognosis. -.247 

" " treatment ..247 

Pediculus capitis, the 245 

Pedulosis pubis, symptoms . .251 

" " etiology 253 

" pathology.. ..253 

" " diagnosis 255 

*' " prognosis 256 

" '' treatment 256 

Pediculosis palpebrarum . . . .256 
" " symptoms. 256 

" " treatment .257 

Phagmesis 141 

Pityriasis capitis 265 

" simplex, symp- 
toms 266 

" pilaris 275 

Phthirius inguinalis, the. . . .256 

Piedra 138 

' ' symptoms 138 

'* etiology 138 

" pathology 139 

diagnosis 139 

Plica polonica, symptoms. . . .303 

etiology 305 

" " treatment. . . .306 

Polish ringworm 303 

Pomades 58 

Prunitive hair follicle 31 

'* papilla 31 

" *' cone 32 

Ringed hair 67 

*' etiology of 70 



S56 



INDEX. 



PAGE 

Bingworm 181 

" dissemiDated 

form 185 

" pustular form ... .185 
" chronic squamous 

form 186 

of the beard 215 

Root sheath, external 27 

internal 28 

Russian dog-faced boy 145 

Scall-head 225 

Scissura pilorum 124 

Sebaceous glands, anatomy of 

. . . .30, 48 
functions of 48 

Seborrhoea sicca capitis 265 

'' " symptoms .265 

Shampoo, the 51 

Shaving 57 

Snarling of hair 58 

Superfluous hair 142 

Sycosis 164 

" symptoms 164 

etiology 167 

" pathology 168 

" diagnosis 170 

" treatment 172 

" prognosis 177 

" f ramboesia 307 

" parasitica 215 

Syphilis 317 

" diagnosis 321 

treatment 323 

Syphiloderma erythemato- 

sum 317 

papulosum 318 

* * f ramboesoif orme .318 

" pustulosum 319 

'* acne-forme 319 

" impetigof orme . ..320 

' ' ecthymaf orme 320 

" tuberculosum 320 



Syphiloderma erythemato- 

sum gummosum 321 

Things case of parasitic dis- 
ease 566 

Tinea favosa 225 

" nodosa .139 

Tinea sycosis 215 

" tonsurans 181 

Trichophytosis capitis 181 

Trichiasis, symptoms 162 

' ' treatment 163 

Trichophytosis capitis, symp- 
toms .181 

" etiology... 186 

" pathology .188 

' " diagnosis. .190 

' " treatment.. 196 

' " prognosis ..207 

barbae 215 

' " symptoms.. 215 
* " etiology — 218 
' " pathology .219 
" diagnosis ..219 
' " treatment .221 
' " prognosis.. 224 

Trichophyton fungus 188 

Trichoptilosis 141 

Trichorrhexis nodosa 128 

" " symptoms.. 129 

" etiology.... 130 

" pathology.. 133 

" " treatment. . 137 

Varieties of hair growth 34 

Vitiligo 326 

" symptoms... 326 

' ' treatment 326 

Vitreous membrane 26 

Wigs 55 

Women less often bald 87 

Yellow hair .78 



PHOTOGRAPHIC ILLUSTRATIONS OP 

SKIN DISEASES. 

[Forty-eight Quarto Plates, Sixty Cases from Life.] 
By GEORGE HENRY FOX. A.M., M.D., 

Olinlcal Lecturer on Skin Diseases, College of Physicians and Surgeons, New York-, 

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HOW TO USE THE FORCEPS: 

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SEXUAL NEURASTHENIA 

^^m^M^k^^ r^^KM (NERVOUS EXHAUSTION.) 

Its Hygiene, Causes, Symptoms and Treatment, 

WITH A CHAPTER ON 

X)±e"b ±ajc? -tlzLe ZtTex^-vo-cLS^ 

By Oeorge Mm Beard, A.M., M.D., 

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*' Medical and Surgical Electricity," etc. 

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be and should be differentiated from hysteria, simple hypochondria, in- 
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which it had until lately been confounded. 

The long familiar local conditions of genital delDility in the male 
—impotence and spermatorrhoea, prostatorrhoea, irritable prostate— 
which have hitherto been almost universally described as diseases by 
themselves, are philosophically ;fnd clinically analyzed. These symp- 
toms, as such, do not usually exist alone, but are associated with other 
local or general symptoms of sexual neurasthenia herein described, 

Th© causes of sexual neurasthenia are not single or simple but 
complex; evil habits, excesses, tobacco, alcohol, worry and special ex- 
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This view of the relation of the reproductive system to nervous 
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PHOTOGRAPHIC 
ILLUSTRATIONS OF 

CUTANEOUS 





SYPHILIS. 



By GEO. HENRY FOX, A.M., M.D., 

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